By Francis Bayes, WCI Columnist
This month, I graduated from my MD/PhD combined-degree program. Earlier this year, I matched to a psychiatry research track residency in a high-cost-of-living area on the West Coast. I will start residency without any debt from medical school. On top of the free tuition, my school paid me a stipend to cover my living expenses for each of the seven years, including three years of PhD. That is about $600,000 in value.
But when I was applying to MD/PhD programs eight years ago, I was not as financially literate, and I was not married. I did not know about the FIRE movement. I didn't grasp how long the journey to becoming an independent physician-scientist would be (spoiler #1: 14 years on average). I cannot quantify the intangible benefits of my MD/PhD training, but as this is a financial column, I'll examine today whether pursuing an MD/PhD is a good financial decision.
(Spoiler #2: I would do it again even if I knew the answer to the question before I applied.)
Why Do Medical Schools Pay MD/PhD Students?
According to the AAMC, out of the 22,000 students per year who matriculate at allopathic US medical schools, about 700 are in the MD/PhD program, which is 3% of all students. The number dwindles closer to 600 by the time of graduation. Most programs pay for tuition (~$60,000) and living expenses ($30,000-$40,000) for both the MD and PhD portions of training—I cannot imagine any circumstance in which one would pay for their own MD/PhD training—because many alumni have to sacrifice income in order to spend the majority of their time doing research in academia.
MD/PhD students are also more likely than their medical school counterparts to choose specialties that have lower-than-average compensations. For example, the national MD/PhD program outcomes study showed that 14% of MD/PhD alumni choose pathology (vs. 1% of MDs) and only 7.4% choose surgery (vs. 12% of MDs). Self-selection is a huge factor, but I think many of my MD/PhD colleagues might have entered more competitive and lucrative specialties if they could have received robust research training during residency.
The same study also reported a troubling trend. The mean time to a degree and mean time to a first full-time job (after graduating from MD/PhD training) have been increasing over the years to 8.25 and 5.88 years, respectively. For psychiatry, the mean time to a first full-time job was 5.6 years, and for surgery, it was 7.1. This data does not include those who graduated after 2014 for the mean time to degree and those who graduated after 2004 for the mean time to a first full-time job. Compared to their classmates who could become an attending psychiatrist after eight years of undergraduate and graduate training, someone who starts their MD/PhD training today could be in training for 14 years before they start working full-time as a psychiatrist.
The psychological effect of seeing your original classmates become attending physicians while you're just graduating from medical school cannot be overlooked. MD/PhDs would be in Years 7 and 8 of “living like a graduate student” with six more years of “living like a resident” remaining. MD/PhDs have to master delayed gratification as much as our PhD dissertation.
Given the above, the question I should have asked is: how far does the money go? In the chart below, I make assumptions that are as favorable for MD/PhDs as possible. Our MD/PhD alumnus maximizes their Roth IRA contribution beginning M1. Our MD-only alumnus would have a student loan burden of $527,000 at the end of their residency training. After these (somewhat unreasonable) assumptions, our MD/PhD alumnus would have about $89,000 more than their MD-only counterpart 14 years after they matriculated together.
However, even if the MD/PhD alumnus starts a full-time job after 14 years of training, the $89,000 gap will close down fast. I have not had a chance to ask any physician-scientist about the details of their compensation, and I could not find any data on the average income of MD/PhD alumni. But a quick scan of online forums suggests that one would have to be a superstar to earn anywhere between $200,000-$300,000 after they complete their training. Hopefully, I am wrong, and one can make more, or I might be naive to consider that such compensation is possible at the beginning of one’s academic career. Since the MD-only alumnus would pay off their loans and start maximizing their retirement savings after year 16, they would be ahead of the MD/PhD alumnus in terms of net worth in just a few more years.
More information here:
How to Stay Focused When Everyone Else Is Getting Rich
What Are the Alternatives to MD/PhD?
If a physician wants research to be their primary endeavor, one may not have a better alternative than a combined MD/PhD training. MD graduates can do research for their elective rotations—or earn a PhD during residency—and then join research fellowships. But their path would not be any shorter, and they would still have student loans (notwithstanding loan repayment or forgiveness programs). According to the NIH’s Physician-Scientist Workforce Working Group Report in 2014, the mean age at which a physician receives their first independent NIH grant is 43.8 for MDs and 44.3 for MD/PhDs. The mean age for MDs has been historically higher, but for whatever reason, the mean age plummeted in 2012 (the last year for which data was available).
While neither path is faster, MD/PhDs are more persistent and successful when they apply for an individual NIH research project grant (RPG). The report found that the first-time award rate of RPG applicants is about the same for MDs and MD/PhDs, but this data likely suffers from survivorship bias. The key metric is “persistence quality,” defined as reapplying for an RPG in subsequent years after their initial application was not funded. MD/PhDs were 8% more “persistent” than their MD counterparts. The difference in persistence was likely due to a combination of differences in commitment and preparation for prior training. Among T32 postdoctoral trainees (yes, many MD/PhDs have to do research fellowships after residency), a higher percentage of MD/PhDs apply for an RPG in the first place, and the award rate was 13%-14% higher for MD/PhDs.
More information here:
‘Opportunity Cost Is a Huge Filter in Life'
I was not surprised on the interview trail—and this column validates my experience—when physician-scientists grilled me on my desire to do research in my career. Right now, I do not think that I will find my career fulfilling without research. I enjoy the process of generating and answering research questions. When I identify something that does not work well, I am going to be frustrated if I lack the skills and resources to improve it.
Money is not the reason to do an MD/PhD; it is why many of us no longer do research. The temptation to decrease my research effort will increase as my family grows and our tastes change. When faculty and former MD/PhDs explained why they (or someone else) left research, the primary reason was the opportunity cost of sacrificing clinical time, not the likelihood of receiving a grant. In five years, I could be writing a column about why I am not continuing my research career. Charlie Munger is right about how opportunity cost is a filter: when two suitors (i.e., clinic and research) are eager to have us and one seems way better, I may not find time for the other.
This column has allowed me to reflect on how my goalposts have moved. When I was working before medical school, I was planning to apply to graduate schools until my mentors persuaded me to pursue an MD/PhD. Now that I am at the end of medical school, I am comparing my lifetime income and net worth trajectory against those of my MD colleagues, not my PhD colleagues. (Don’t get me started on comparing myself to my college classmates and software engineers!)
I do not believe that I can stop the goalposts from moving. I can only adapt and make sacrifices for what I can control. I realized that I could improve my odds of becoming a physician-scientist by decreasing the financial effect of my career choices. This is one of the reasons why the program where I matched was high on my rank list (I will share those reasons in a future column). My wife and I will be moving to the state where she grew up and her parents still live. We are thankful for everyone who has made this seven-year journey possible and excited for the new opportunities that will be coming our way.
If you were an MD/PhD student, are you happy with how it turned out? What were your pros and cons? If you went the MD route instead of doing research, did that turn out to be the right decision?
Appreciate the article. Would NOT do an MD , PhD again. Strictly clinical now. Absent the financial advice or insight early in my career, can’t say I’m in a better financial position than my contemporary MD counterparts. Doubling down on a post doctoral research fellowship, probably was the most financially problematic decision, not to mention the strain it put on my family with time commitments to research. Don’t regret the journey taken, it helped clarify what’s most important in my life. Charlie Munger is a wise man, the financial incentives of clinical practice probably outweigh those of research unless you can see a way to starting a successful business or collecting on royalties from anything you patent in your research.
Thank you for sharing your journey. I’m hoping that I will have more clarity after doing a research track residency and having kid(s). On the interview trail, it seemed like many MD/PhD research tracks decide whether to continue research in their final year of residency or the first 1-2 years after residency.
Can you comment on the value (to “the public” etc.) of MD/PhD doing research rather than PhDs in similar fields doing so? How would Psychiatry medical care now and in the future be different if all Psychiatry research was done by PhDs consulting MDs at times/ following MDs’ patients with the MD’s cooperation? Would any MDs be willing to take the time that would demand of them as so many now do med stud and resident education?
While MD/PhDs may be less likely to become pioneers in methodology such as bioinformatics (Francis Collins being the counter-example), PhDs will rarely appreciate the complexity and diversity of clinical presentation and complications from treatments (except perhaps clinical psychologists). True “bench-to-bedside” is becoming rarer, but MD/PhDs clinical experiences as a resident can be enough to launch full-time research careers because research questions grounded in reality tend to be more “high-yield.”
If no MDs were primarily doing research in psychiatry, we would repeat what happened in the 2010s (granted it was under the leadership of Dr. Tom Insel who was a clinician-scientist) and go nowhere. As for med ed, it would depend on how they spend their clinical time. Less likely to directly supervise if they are doing outpatient.
I finished the MSTP in 7 years; followed by residency and fellowship over another 7 years. Although I started an academic career at least 3 years later than my original medical school classmates, I had a clean slate, with no debts. I had the opportunity to pursue clinical or research tracts, and followed my drive to specialize in interventional cardiology. In terms of financial considerations, a peak salary of 400k, while lower than many in private practice, afforded as high a lifestyle as I could want, while building equity. Combining accumulated funds with a government pension (from a decade in the VA), I could retire at 62, with FEGLI health insurance coverage.
For pre-meds considering M.D.-Ph.D. programs, they should pursue this track for a passion and commitment to research and an academic career, not for maximizing financial achievement. However, the advantages of starting a career free of debt, and the level of opportunities afforded by the combined degrees, should more than outweigh the costs of the few years’ delay they incur.
Thank you for sharing your journey. I 100% agree about choosing MD/PhD based on passion and commitment. Financial incentives should not be a factor at all. I was always puzzled by my classmates who thought I would be financially ahead of them. It’s what motivated me in part to try crunching the numbers for the column.
MSTP,
“I could retire at 62, with FEGLI health insurance coverage“
Are you still at the VA? I thought you had to work at VA for more then 10 years to get the health insurance coverage?
I finished my PhD in Biochemistry on full scholarship in 1980, then enrolled in 2 year Med School program at U of Miami Med. School. This PhD to MD program no longer exists. After Internship in Internal Med and 3 yr.Residency in Ophthalmology, I was hired at a major academic research institution for a paltry salary and advised that Research Grants would be necessary to augment my salary. I was surprised to discover that I was no longer eligible to apply for a “NIH young investigator award “, and would have to apply for RO1, which was highly competitive and therefore unlikely to be funded. Although I was successful in getting a few private grants, the amounts were barely enough to cover the cost of the research and not the salary. Ultimately, I left the University after a few years and remained in a successful private practice for 30 years. I am recently retired. I have to admit that the PhD education in Biochemistry was a fantastic background for medical school and clinical practice. It is hard for me to say whether I would do it again because I do not think I would have been of as much value to my patients, students and colleagues, however the institutions that funded my education might feel otherwise, with respect to the cost they incurred to educate me.
Thank you for sharing your journey. I think experiences like yours are one of the reasons that my program focused less on having us become experts in a siloed field (eg, biochem, cell bio, etc.) and encouraged us more to learn how to study a disease. After all, so many MD/PhDs choose a specialty that is unrelated to their PhD.
Given the difference in rates at which clinical work and research are paid, ot would be rare to find adding the PhD was a positive financial move. Same as for rarely will pursuing research lead to a higher income than purely clinical work.
People get PhDs and do research because they want to, not because it is the highest paying career path.
Same as for why people enter general peds, rather than neurosurgery. Neurosurgery pays better but many people would rather be pediatricians.
Thank you for your comment. I 100% agree. Just as the OG WCI says…longetivity over peak income. After all, many clinician-scientists choose to work beyond age 70 because they love what they do.
I did my PhD as a way to get into med school after a less than stellar first year as an undergraduate, which pulled my GPA down. I had already worked in a lab as a summer student and enjoyed the research I had started, however it was a means to an end, as my goal was always to be a doctor. Despite the opportunity costs of 4 years for my PhD and one year of post-doctoral fellowship, prior to med school, and then 3 years of subspecialty training after residency (Oncology), I retired 2.5 years ago at age 58. I also married the lab tech I worked with! Other than a bit of delayed gratification, I have no regrets at all !
Thank you for sharing your journey. Congrats also on your financial independence! My wife isn’t in research or healthcare, but we got married during my PhD years, so I will also never say that I regret doing my PhD.
Dude Francis congrats on the MD PhD man! Although maybe not the best financial decision, do you find value in that those researcher years may not have been as hard-core as redidency training and there was time to spend with family and friends?
Thank you for your always kind comment! The PhD years were a nice breather, and my wife and I (as well as my parents) appreciate the experiences that we’ve had because of my schedule’s flexibility. The trade-offs are: (1) living like a resident for a longer period especially if I do a research fellowship and (2) becoming financially independent later. I hope that we’ve made the trade-offs worthwhile, and I think having kid(s) and my parents aging will help me appreciate the PhD years even more later.
Besides the obvious late start on financial productivity – If you think MDs are bad with money, PhDs are worse. There is a culture of not caring about money in academic science, and that can help you take your eye off the ball. As a clinician scientist you spend you extra more on your research, not on projects that generate personal wealth. For so many reasons it is not a good financial move. Only do it if you want to be a clinican-scientist. Living like a resident is an easier path to being debt free than MD/PhD.
I was always puzzled by my classmates who thought I would be financially ahead of them. It’s what motivated me in part to try crunching the numbers for the column. I think many trainees are daunted by debt because it’s hard to grasp how much one could save and spend on attending salary.
Like the author, I came to the MD-PhD program as an alternative to a straight PhD. I think one of the main societal benefits of the program is drawing talented people into medicine who would otherwise have been basic scientists. I don’t know the latest statistics, but only a small portion of MD-PhD graduates go on to be federally-funded investigators. Not only is the financial pull of clinical medicine strong, but it is also inherently difficult for clinician-scientists to compete with PhDs who do research full-time. The other issue with MD-PhD programs is sequencing. After devoting 3-5 years on the PhD, most trainees take a long (4+ years) break from research for residency. During that time, they lose much of their competitive edge in research as science moves on in the meantime. They may have a bit more experience then their MD-only counterparts in a T32, but at that point it’s a small factor compared to the mentor you happen to get and how much (if at all) your research project takes off as you make the transition to junior investigator.
If medicine is the plan from the get-go, I think people are better off going to a reasonably-priced med school and looking at doing a year at NIH or some kind of masters in clinical research. Most MD-PhDs do basic science, but I would argue the real edge would be getting training in clinical research so you don’t end up competing in basic science with those full-time PhDs.
Sorry for my late reply, but perhaps more timely given I’m now in my second year of residency.
Research track residency programs (like the one I’m in now) allow for some continuity, but many MD/PhDs end up pursuing a specialty that is not related to their PhD or changing their research area based on the available mentors at their new institution. Regardless, I think MD-PhDs do have an edge over their MD counterparts during residency because they are more likely to match into the research track programs and receive internal grants to fund their projects.
I do agree with your point about competing with full-time PHDs. I am leaning towards clinical research, but we’ll see.
It’s my understanding that MD/PhDs are also in demand for medical school faculties.
So it might be a good route to go if you want to teach as an academic faculty member.
As far as I know, the demand for MD-PhDs is for their research, not for clinical teaching. Any edge (see my reply immediately above) would be nullified by productivity.
No one, at least that I know of at the time (i.e. before explosion of VC and biotech) pursued an MD/PhD for $, but for personal goals as did I.
I didn’t have perspective on the MSTP track until a chance encounter during a 11pm elevator ride from one lab to another during my research time. I ran into an esteemed MSTP alum, now a junior faculty member, who was way smarter, insightful, and accolade/award-winning than me. I asked him why he was there so late. He shared that between his 1/3 time in supervising his lab & research, 1/3 time as an attending, 1/3 time grant writing, and 1/3 time teaching, it was his routine, and he was NOT joking about his time allocations. I later noted that there had been no mention of his new wife or personal time.
That led to some thoughtful discussions with my new spouse and some difficult decisions about career track. I ultimately chose to combine my interests in a pharma career and skipped the ivory tower rat race. While there are many similarities btwn academia and pharma, pharma provided greater career flexibility and personal time while still allowing me to make practical real-world contributions to health care in shorter time horizons.
My husband and I are coming upon a similar revelation, 3 kids in and facing the reality of tenure track junior faculty expectations. Would you be willing to chat more about your transition to industry?
Sorry for my late reply, but perhaps more timely given I’m now in my second year of residency.
From what I’ve been told, transitioning from industry to academia is easier than the other way around. If I were not interested in clinical practice at all, I have always thought I should pursue working in the industry initially.
Another take as a md/phd currently on the job market after completing residency/fellowship. The calculation was monetary, but not in the typical way as shown above – not having crushing levels of medical school debt and the gap of the PhD years allowed me to pursue some side hustles and venture-type investing, which made a difference (also, renting out the property I lived in as a md/phd produced another income stream – bought post 2008 crash, so values were atypically low). Thus, I’m starting out attending-hood with no debt (besides mortgage) and net worth close to 1M. This isn’t typical though and results may vary. But the lesson: not everything is Excel sheets and financial models; embrace spontaneity and luck.
Sorry for my late reply, but perhaps more timely given I’m now in my second year of residency.
Did you make the calculation about the side hustles before you applied to MD/PhD programs? I would imagine you were more likely to buy the property because you knew you would be there for at least 7-8 years.
Totally agree about spontaneity. I would not have had the opportunity to learn about personal finance and write for WCI if I did not have the PhD portion in medical school.
Buying a house definitely was contingent on getting admission to an MD/PhD instead of an MD — most rent-buy calculators stipulated 5 years as the breakeven point, factoring in commissions and such, even at the low interest rates then. Interestingly, the location I was in (coastal Texas, to not give too much away) basically did not appreciate until COVID, where properties increased over 100% after. One small perk that helped was ARRA 2009, which essentially subsidized a large portion of the downpayment then.
No, the hustles/investing calculation didn’t make it in before application. I was quite committed to an academic career at that point. But I believe that having that PhD “break” (not really a break, but time to explore other things) made it possible. As an aside, I had a terrible PhD to MD transition due to rotation scheduling and personal family matters during that time, but survived it.
Another relevant factor had to be market returns at the time. In 2010, the US markets just went through the worst set of 10-yr annualized rolling returns since 1939 (!). Thus, the estimated time value of 4 years of attending salary was likely too pessimistic. In contrast, research seemed like a stable career option.
static.fmgsuite.com/media/documents/bc618705-6161-4c00-be7f-c667c90c61b5.pdf
My husband and I are both md phds new attendings. He is 100 percent clinical (likes to dabble in clinical research) and I am working on a k and 50 percent protected. I do not regret my phd because it let me get my current job and set me up for a research career. I do find it hard though when my job conflicts with my job. Financially, I probably am doing worse as I did my mdphd in high cola but I feel my life is much more rewarding.
Sorry for my late reply, but perhaps more timely given I’m now in my second year of residency.
One thought I’ve had is that having another high income partner might increase the chance that an MD/PhD pursue research because they would have less financial burden to be the primary breadwinner. Regardless of their partner’s income, I have heard from a few junior investigators that it still stings to compare their income (and lifestyle) to their residency and med school classmates.
I’m in college and thinking about the md/phd route. I understand this article was comparing the difference between md vs md/phd but given you were originally thinking about phd only – how would you compare those two options financially? How does the phd only route compare to md/phd if you think you are more interested in research?
Financially, it depends on the PhD and its length because many MD/PhD programs try to help their students finish the PhD portion in 3-5 years (our PD made sure we finished ours in 3). Unless someone is a superstar MD/PhD, they should do a residency as a fallback. So that’s at least 4-7 additional years of training if you include clinical or research fellowship. Your salary as a physician will depend on how much clinical time you do and how much your institution pays you extra on top of NIH cap of ~$220K.
On the other hand, one could optimistically finish their PhD and post-doc in the same length as typical MD/PhD training (7-9 years). Even if you become a PI ASAP, your salary will depend on your institution’s pay scale and AFAIK likely won’t get higher than what a physician-scientist who does 100% research (because the latter will always be more rare and valuable).