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:

Splurge on This, Not on That


‘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.

MD/Ph.D. students

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? Comment below!