 ​Unfortunately I tweeted this five years ago and it’s still true. Introduction
I have enjoyed my MD/PhD training and am excited for my future career. But in some sense, I think I got lucky: there are good reasons to do an MD/PhD, and bad reasons to do an MD/PhD, and I decided to do an MD/PhD for both good and bad reasons. In this blog post, I review some of those reasons—as well as others that I think are common—in the hopes that your decision-making process about whether to do an MD/PhD will be better than mine. Context Prior to starting college, my plan was to eventually work internationally as a wildlife vet. During college, I read books by Paul Farmer, studied and interned in middle-income countries, and learned about GiveWell. These things convinced me that I could potentially do a lot of good by pursuing a career in global health, and I switched from being pre-vet to pre-med. However, I was always more academically drawn to the humanities and social sciences, so I pursued an independent concentration in human rights (which was ~80% political theory classes, plus a bit of anthropology, sociology, history, and philosophy). I decided to do an MD/PhD in the social sciences because: (1) it seemed like a good way to reconcile my diverse academic interests, (2) I was drawn to a career that would allow me to both help people directly (via medicine) while also addressing structural issues (via my research), (3) some people I really admired (and whose careers seemed amazing) had done MD/PhDs in the social sciences, (4) it seemed like a powerful degree combination that would allow me to do a lot of good, and (5) I wasn’t sure what exactly I wanted to do, and earning a combined degree seemed like it would leave open many career paths. Even now, all of those reasons intuitively seem reasonable to me, but when subjected to closer scrutiny, some start to seem less compelling. There were also other reasons floating around in the background, which I’ll get into. Six bad reasons Reason #1: It’s free Elaboration: If you do an MD/PhD, you will generally not pay for medical school, and will typically earn a ~$40k stipend for eight years; by contrast, the median medical student will accrue $215k of medical school debt. So just to do some simple math, you will earn about $320,000 ($40k/year * eight years) as an MD/PhD student, whereas if you were to only earn an MD, you would lose about $215k. You might therefore think that the financial value of the degree to you is at least $320,000, and possibly more like $535,000 (if you otherwise would have just done an MD, although this number is overstated, since many MDs don’t repay all of their medical school debt due to programs like public service loan forgiveness). Why I don’t endorse this reason: How financially advantageous it is to get an MD/PhD will depend on what your counterfactual is; if you’re comparing doing an eight-year MD/PhD to doing an eight-year English literature PhD, I would agree that the economic value of the MD/PhD is higher. But when compared to just doing an MD (which seems to be the most common alternative for people who are considering applying to an MD/PhD), you will lose (on average) four years of an attending’s salary. How much this is will depend a lot on your specialty, where you practice, and so on, but the average attending physician earns around $350k per year. This means that the amount you could expect to make in four years as an attending is in the ballpark of $1.4 million—i.e., a lot more than $535,000. (Of course, this is a simple calculus: if you are the kind of person who wants to do an MD/PhD, you are probably not super much in it for the money. My argument is just: “this seems like a financially good deal” is not a good reason to do an MD/PhD, because it likely isn’t.) Reason #2: You want to prove something to others Elaboration: My pre-med advisor told me that I probably wouldn’t get into medical school unless I took more biology classes. I was pretty sure he was wrong, and him asserting this lit a fire under me to prove that. This story is one I have heard from others, too—maybe it wasn’t your pre-med advisor, but instead your parents, or an unsupportive teacher, or a society that didn’t believe in you, and you want to prove them wrong. Why I (basically) don’t endorse this reason: Proving people wrong is one of life’s great joys. I am especially sympathetic to wanting to do this if people systematically underestimate you. But it’s worth interrogating this reason closely. First, proving people wrong—like posting about how you got into an MD/PhD program on social media—tends to only provide fleeting satisfaction. “I showed you!” likely isn’t going to provide sustained motivation or happiness throughout the ~2,500- to 3,500-day grind of doing an MD/PhD. Second, there are often multiple ways to prove people wrong—you can do great things (and show people they underestimated you) via multiple paths, not just by doing an MD/PhD. Finally, while it is true that random people you encounter will be impressed when you tell them you are getting an MD/PhD, their opinions usually don’t matter much; the people who will shape your career will evaluate you primarily based on the quality of your work, not on whether you have an MD/PhD (in part because you will likely apply to positions other people with MD/PhDs or similar academic credentials will apply to. I think it can also be the case that doing an MD/PhD sets evaluators’ expectations higher—like: “You had several years to do research and publish stuff—what do you have to show for yourself?”) Reason #3: You want to prove something to yourself Elaboration: Part of the reason I wanted to do an MD/PhD was to prove to myself that I was really academically capable (something I was insecure about because I had academically underachieved in high school, and then been admitted from the waitlist to my college class). Why I don’t endorse this reason: First, degrees are not going to give you good self-esteem. It can seem this way from interacting with arrogant people who have fancy degrees, but I suspect most of these people were either arrogant to start with or are actually insecure, and this manifests as them touting their achievements. Second, many things about medical school and graduate school will probably make you feel bad about yourself; for instance, being around people who are smarter than you, not getting enough feedback (or getting mediocre feedback), the lack of clear standards and expectations, taking exams that you won’t always perform well on, and experiencing lots of rejection (e.g., from journals). In short, while it intuitively seems like doing things smart people do would make you feel smart, it often doesn’t work this way. If you want to feel intellectually better about yourself, I would recommend: (1) aging, (2) surrounding yourself with supportive people, (3) cultivating other values, and (4) defining and pursuing intellectual projects that you enjoy, independent of whether other people are impressed by them (e.g., writing blog posts, learning a language, or reading books). These things won’t always make you feel more intellectually capable, but can help you realize you’re intellectually capable in the ways you care about, while also helping you recognize that there are (many) things more important than being smart. Reason #4: Doing an MD/PhD will allow you to keep your career options open Elaboration: Part of the reason I wanted to do an MD/PhD was because I wasn’t sure whether I wanted to do academic medicine, work (potentially internationally) on global health issues, or focus on health policy domestically. Doing an MD/PhD seemed like a good way to preserve all of these options. Why I don’t endorse this reason: First, doing an MD/PhD to keep career paths open is like buying a chocolate bar for $1,000; no one is disputing that chocolate is good, but you just shouldn’t spend that much on it. Similarly, I think there is a lot to be said for making some sacrifices to keep your options open. Many of us are taught from an early age to do this—by, for instance, working hard in school. But the time and opportunity cost of doing an MD/PhD is just way too high to justify doing one for this reason, given you will spend at least 20 percent of your career just earning your degrees (eight out of about 40 years, and this doesn’t account for residency training, or the fact that you will be working especially hard during those years). Given the time investment involved, it doesn’t make sense to do an MD/PhD to achieve some vague, poorly-defined end. Second, the “keeps options open” thing is a bit of an illusion, since doing an MD/PhD forces you to forgo career flexibility during your 20s—a crucial period of career exploration for most people, since many do not yet have kids, a long-term partner, elderly parents, and so on, and are therefore more mobile and have fewer financial and other obligations. During my MD/PhD, I have had to pass on applying to multiple jobs that I would’ve otherwise been very interested in. None of these specific opportunities will be available to me when I complete my training because they’ll have hired other people. (That said, it’s not like you can’t explore at all: I did consider taking a gap year from my PhD to do a one-year journalism fellowship, and I also applied to a summer internship that would’ve meant taking a two-month break from my research. In short, some exploration is possible, but much less than would be possible if you weren’t doing an MD/PhD.) Finally, an MD/PhD preserves very few options that wouldn’t be available if you “just” did an MD (or an MD and an MPH, etc.). An MD/PhD likely keeps some doors—particularly those in academic medicine—propped slightly further ajar, and so there may be this diffuse, vibe-y way in which it seems to confer flexibility and choice. But I suspect most successful MD/PhDs could have achieved similar careers with just an MD if they had prioritized acquiring research training by other means (e.g., during medical school or fellowship). The people for whom doing an MD/PhD does meaningfully preserve career options are people who would not have otherwise done medical training, since it’s impossible to practice medicine without an MD or DO. But if you’re considering spending at a minimum seven years completing clinical training (medical degree and residency) because you think you may want to practice medicine, I would strongly advise you to do much less costly things to resolve this uncertainty—shadow for many hours with many different kinds of clinicians, take a job in a clinical setting, talk to lots of doctors about their careers (including ones who have given up clinical practice), and so on. Reason #5: A couple of people whose careers you want to emulate did MD/PhDs Elaboration: Looking around the world and identifying people whose careers you’d want to have is a very natural way of picking a career. I suspect part of the reason we do this is because people ask us from an early age what we want to be when we grow up, and “who do I know who has a cool career” is understandably how we first learn to reason about this. Why I don’t endorse this reason: I think what matters is: what percent of people who did an MD/PhD have careers that you would want. You may be able to narrow the reference class further: for instance, I would consider what percent of social science MD/PhDs have careers I would want, rather than looking at MD/PhDs writ large. The reason I do not think you should try to emulate the careers of one or two people is that their experiences may not generalize. As just one example of this, shortly after I applied to MD/PhD programs, I heard Jim Kim—an MD/PhD, former director of the World Bank, and friend and colleague of Paul Farmer’s—give a talk where he explicitly advised the many pre-meds in the audience not to try to emulate Dr. Farmer’s career. His rationale (put more gently and eloquently) was something like: Paul Farmer was exceptional in a number of ways, and trying to emulate him is like watching Usain Bolt run a race and deciding to become an Olympic sprinter. I left the talk feeling a bit indignant, but now realize that Dr. Kim was right: the way Dr. Farmer approached his medical training—spending similar amounts of time in Haiti and Boston—is prohibited by most medical school curricula, and would be unfathomably hard to do. In short, Dr. Farmer was able to have his exceptional career because he had a specific combination of values and traits—alongside important contextual factors—that made it possible for him to do the things he did. This is not to say that you are not exceptional, but you likely have different values and traits—and are operating in a different context—than the person whose career you hope to emulate, and these things will make it impossible to chart their exact course. Given this, it makes more sense to consider the typical career that an MD/PhD in your field has. Assume you'd end up doing that. Would you be happy? If you would only be happy doing something that a small fraction of MD/PhDs do, I think it is worth seriously considering whether there are other (ideally more direct) paths towards doing that thing. Reason #6: It’s nice to have a clear, well-defined plan for how you’ll spend the next 7-10 years Elaboration: I don’t think this is explicitly surfaced as a reason for most people, but the prospect of being able to punt a lot of career and life decisions until you near the end of your training is reassuring for many. I think part of me had also assumed that by the time I was 30, I would have figured out how I wanted to spend my life, and I would then have the degrees I needed to do it. But for most people, career uncertainty (and the existential angst that accompanies this) is just a perennial feature of life for people who care a lot about their careers and have options. If anything, I’ve perhaps become more uncertain about what career I want to have, particularly as certain options have started to seem unrealistic, or misaligned with other things I care about (like not spending tons of time away from my partner). Why I don’t endorse this reason: First, if you are the kind of person who is inclined towards existential angst, and is drawn to MD/PhD training because you think it will exempt you from said angst, I promise you will find lots of other things to feel angsty about during your MD/PhD, like: What PhD should I do? What lab should I join? What medical specialty do I want to do? Do I even want to do a residency? How hard do I want to work? Should I marry this person? Do I want to stay in this city? Do I want to have kids? Will having kids now versus later be worse for my career? Moreover, you will likely feel angst about the paths that doing an MD/PhD has prevented you from taking. As you see your friends who didn’t do MD/PhDs move to different cities, get different degrees, change careers, make more money than you, and so on, a part of you may wonder: “What paths might I have pursued during my twenties had I not decided to do an MD/PhD?” In short, fretting about the roads taken and not taken is a (healthy in moderation) inevitability for many people, and doing an MD/PhD will not exempt you from this. Equally important, though, is the fact that your values are likely to shift during your twenties, and depending on how they shift, having a clear, well-defined plan for the next 7-10 years may cease to be a good thing. I had assumed by the time I graduated college, my values and goals would remain relatively stable for the rest of my life, since I attributed past shifts to the process of growing up. I did not anticipate that I would change about as much between the ages of 23 and 30 as I did between the ages of 16 and 23. I don’t think this is true for everyone, and if you’re the kind of person who has known for a long time (say, more than five years) that you want to do an MD/PhD, you may not need to worry as much about your values and goals shifting. But if you are someone who has repeatedly changed your mind about what to do with your life, and are drawn to an MD/PhD because you think it will provide you with some certainty and structure, I am inclined to think that this is actually a reason not to do an MD/PhD, since your priorities may continue to change, leaving you feeling constrained by the rigidity of a 7-10 year degree. What are good reasons to do a MD/PhD? I think a natural way to decide whether you want to do an MD/PhD is to think about this decision like the decision about whether to go down a particular water slide at a waterpark—primarily: “does that water slide look fun?” (i.e., the MD/PhD training) and less: “will it spit me out in a pool I want to be in?” (i.e., the remainder of your career). I do not, however, think this is the right way to think about whether to do an MD/PhD. Instead, I think it makes more sense to focus on the pool you want to end up in, and then work backwards: there may be multiple slides into that pool, a few ladders, and you could always just jump in off the edge. Which pool? I think MD/PhD training makes the most sense for people who want to end up in the academic medicine pool, and specifically, for those who want to spend the bulk of their time doing research, and a smaller percentage of time doing clinical medicine (i.e., somewhere between a 60/40 and 80/20 research/clinical split). I used to think MD/PhDs made sense for people with other career goals goals, but I’ve become increasingly skeptical that doing an MD/PhD is the best option for most people who don’t want to do academic medicine. The reason I think this is because for almost anything else you want to do in medicine (or research), there is probably a more direct path. If you want to spend most of your time practicing medicine, you may not need the PhD (especially given you’ll have lots of time to do research during your medical training—e.g., one year during medical school and two years during fellowship). If you want to spend less than 20% of your time practicing medicine—or are unsure whether you want to take care of patients at all—I don’t think it makes a ton of sense to spend seven years doing medical training (at least until you become more certain about wanting to practice medicine). I also think that if you’re someone who is on the fence about medicine (as opposed to the PhD), other, non-MD clinical degrees may be worth considering instead, since you may be able to acquire the clinical knowledge and skills you need in less time. Finally, people who want to pair clinical practice with something other than research (e.g., policy work, hospital administration, or consulting) should strongly consider degrees aside from a PhD (e.g., an MPH, MPP, MBA, or DrPH), since most PhD programs aim to train researchers, rather than practitioners, so may not leave you with the most relevant skillset. Which slide? My claim that you should pick an efficient path towards the pool that you want to end up in warrants defense, since someone could plausibly respond: “Why should I take the most direct path to the pool I want to end up in? MD/PhD training seems fun.” And I do think it is super important to choose a path that you’re viscerally excited about. Having taken three gap years myself, I also don’t want this advice to be misconstrued as “don’t explore options,” but rather: “all else equal, if there’s a less costly, more efficient path toward the same final professional destination, and that path seems fun too, choose the efficient path." Part of the reason I think you should consider other options rather than an MD/PhD if another path can get you to the same destination is that MD/PhDs are partly taxpayer funded—and MD/PhD spots are limited—so there’s an argument for not using limited public resources if you don’t need them. (And to be clear: if you need them, you should use them.) There are also other reasons to pursue a more efficient path: (1) training efficiently will likely benefit you financially, (2) ideally, it seems better—less stressful, more conducive to long-term success—to be more established in your career by the time you have kids, if you want kids (although I can't speak to this personally), and (3) people tend to have more impact as they become more established, so if this is something you care about, it’s better to train efficiently. Wanting to pursue a 70/30 career in academic medicine also does not necessarily mean you should do an MD/PhD the standard way (i.e., you go to college, potentially do a post-bac, do a 7-10 year MD/PhD, and then complete residency/fellowship). This is because there are multiple ways of attaining a career as a physician-researcher; for instance, you could take several research years rather than doing a PhD, or could do your clinical training first, and then do a PhD later (though this will tend to be costly). It’s worth flagging that this line of reasoning puts pressure on whether the standard MD/PhD path should be the standard physician-researcher path: if there are potentially less costly, more efficient ways of attaining the same career, why pursue 11+ years of post-university training (MD, PhD, residency)? My goal here is not to weigh in on the optimal way to train physician-researchers. But I would caution you against assuming that just because the path described above is the standard path, that means it is the right path for you (or even the right path for most people who want to become physician-researchers). For instance, I think there’s a strong argument for completing clinical training first, and then choosing a research career that maps onto your clinical interest (e.g., breast cancer research if you’re a breast oncologist) and clinical lifestyle (e.g., less time-sensitive projects if you’re often on call for your patients). Deferring your research training until you have a very clear sense of what research you want to do may also allow you to pursue the specific research skills you need, rather than investing a lot of time into cultivating ones you won’t use. For instance, my partner has an MD (and not a PhD), but is better at using statistics in his research—despite the fact that I have taken much more coursework in this—because he learned the specific skills he needed to do the projects he wanted to do. By contrast, I learned some general skills during the first two years of my PhD that wound up not translating that well to the research I did during the latter part. To summarize: If you don’t want to do academic medicine—and specifically a 60/40 to 80/20 research:clinical split—I think there are usually other training paths that make more sense. If you do want to do the 60/40 to 80/20 academic medicine thing, it’s worth considering whether there are non-MD/PhD paths to achieving the same goal, and systematically assessing the pros and cons of those options. If you want to spend most of your time doing research and some of your time practicing medicine, have systematically considered other paths, and think you’d really enjoy and benefit from MD/PhD training, I think it’s reasonable to do an MD/PhD. Next steps If you’re not sure whether to do an MD/PhD, here are some things I would consider doing:
Ultimately, these kinds of decisions are just really hard to make, and thinking about them a lot won’t always leave you sure of what to do. But thinking about these decisions systematically will tend to produce greater clarity, giving you more insight into your goals, values, motivations, things you want to avoid, and the relevant tradeoffs associated with different paths. Gaining clarity will help you make better decisions amidst uncertainty (and may help you grapple better with the uncertainty that remains). Good luck!
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