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an online version of the magazine Fall 2008
Annals of Hopkins
 
 

Issues of Identity

Deciding whether to start an MD/PhD program became a soul-searching question 40 years ago at the School of Medicine.

 

By Elaine K. Freeman

 

Barker
> Paul Talalay, captured here in 1997, was architect and first director of the Medical Science Training Program at Hopkins.

It may come as a surprise to learn that the Johns Hopkins School of Medicine—the place where the concept of training physicians in science was born—didn’t leap at the idea of establishing a formal government-sponsored program that would do just that. In 1964, in fact, when the NIH launched its Medical Scientist Training Program (MSTP) and offered federal grants to med schools agreeing to operate one, Hopkins wasn’t biting. True, the program would support handpicked, highly-motivated students in a formal MD/PhD program—but school officials foresaw big problems.

At the heart of their reluctance were existential questions: What did the School of Medicine want to be? Where should it place its emphasis? An institute producing only world-class scientists?  A school turning out only world-class clinicians?  A blend of both? 

Certainly, Hopkins had long enrolled a handful of MD students who went on to earn a PhD—or vice-versa. But these few always completed one degree before starting the other. The Medical Scientist Training Program would be organized differently. Students would start with the first two years of the MD program, then break away for three or four research years and finally end with the MD clinical rotation. In other words, they would begin med school with one set of classmates and graduate with another. And because the federal stipend would allow this small, elite group to graduate virtually debt-free, it would become a magnet for a flood of applicants. Furthermore, they would receive intense mentoring and have the time, unavailable to others, to devote to one problem.  MSTP students would be different from their classmates, so they would be treated differently. And that, argued those opposed to the program, would change the very nature of the school itself. Finally, recalls pharmacologist Paul Talalay, “my colleagues were telling me not to send over scientists to care for sick people.”

Fortunately, the critics lost their battle. And so, in 1975, the School of Medicine acquired its first federal grant for a Medical Scientist Training Program. Talalay, the program’s chief advocate as well as its architect and first director (1972-82), began recruiting students via an announcement sent only to the School of Medicine. Immediately, the number of students interested in earning both an MD and a PhD tripled (from three to nine in one year). Among those signing on for the new program were two of its future directors, Steve Desiderio (1992–1999) and Robert Siliciano, the current head.

Recalling his determination to go for the MD/PhD, Siliciano says that splitting off from his MD classmates was “a big decision.” These programs “were starting elsewhere, but it wasn’t a well established path yet,” he recalls. “I had concerns about applying, but I loved research, and it seemed a great opportunity.” Once enrolled, Siliciano says that switching back and forth from one cohort of classmates to another didn’t bother him. He relished making new friends among the graduate students, including his future wife, biochemist Janet Siliciano. What was hard, he says, was “watching MD classmates leave after four years for exciting internships and residencies when you’re working on some obscure research project.”

But Talalay had anticipated such emotional swings and arranged activities that promoted camaraderie among students in the fledgling program. “We had monthly dinners,” Siliciano reminisces, “where faculty members talked about their careers in science. Students prepared the meals, but after a particularly disastrous spaghetti dinner I cooked, Dr. Talalay decided to move the dinners to the faculty club.”

In the end, Siliciano says, going through another year of rigorous course work was pretty awful, “but the courses were at a much higher level than med students get. I loved research, and this enabled me to do modern research.”

Indeed, from the program’s start, MD/PhD students were involved in some of the most significant research to come from Hopkins. They worked on neurotransmitters, neuroreceptors, and nitric oxide in the lab of world-famous neuroscientist Sol Snyder. They took part in pacesetting work on breast and colon cancer genetics with the eminent scientists Bert Vogelstein and Ken Kinzler. And they began publishing groundbreaking work in some of the most prestigious scientific journals.  

Picky about the labs where they’d do their PhD thesis work, students moved through several research rotations to find a good fit. Faculty were anxious to recruit them, Siliciano says. “They’re so bright and talented, you can give them free rein. They don’t just carry out experiments designed by mentors. They actively pursue their own ideas.” 

With such a research focus, of course, the program was bound to stir tensions between clinical and basic science faculty. And it did. According to Richard S. Ross, dean of the School of Medicine during the MSTP’s early years, “some of its prestigious scientific preceptors thought that MD/PhD students didn’t need to pay much attention to the patient care side. I had to fight to make sure it was a balanced program and to remind people that this also was an MD program.”

Basic science faculty, meanwhile, were rankled by the program’s admissions process. Snyder says that as the cost of a medical education increased, securing one of the 10 new MD/PhD slots each year at Hopkins became like getting a Rhodes Scholarship. Unlike many of their classmates, these 10 students would graduate without debt, thanks to free tuition, health insurance, and the government stipend.

But applicants to the MD/PhD program went through the same admissions criteria as regular medical students. Only in 1992, when Desiderio took over as director was he able finally to lobby successfully for a separate admissions committee. Ever since, applicants have undergone an intense screening process that includes multiple interviews with full-time scientists who teach in the program.

“We wanted to be sure the students had a passion for research,” says Snyder, “and weren’t just driven by the money.”

Over the years as medicine has grown increasingly sophisticated and concerns like genetics, translational research, and public health have become ever more relevant to patient care, the program has kept pace. Today, students choose their PhD specialty from 15 departments at the School Medicine or from fields such as biostatistics, international health, and bioethics at the Bloomberg School of Public Health.

Among the 40 U.S. medical schools with MSTP programs, Hopkins now has the most government-funded slots (50). At the program’s last formal review, Hopkins received the highest best score ever achieved—and a reward of one additional stipend. Extra points were awarded for recruiting the most minority students. “But we were also cited,” says Siliciano, “for what happens to our students. They finish on time [average of  7.3 years], publish an average of 6.3 peer-reviewed papers while in the program, and 80 percent go on to academic careers. They are phenomenal.”  

Still, despite the fact that the MD/PhD program received 500 applications last year for its 10 entry slots, the program probably won’t get larger, according to David Nichols, vice dean for education, so it can continue to provide great attention to each student, doing “a fabulous job of selecting and nurturing them.”

But just as in 1970, the argument continues. Few side with the extreme view that the School should have all MD/PhDs. There is wide agreement among the basic scientists, however, that, with its rich applicant pool, Hopkins readily could double the number of MD/PhD candidates without diluting the program’s quality. “Many med schools can train good doctors,” Snyder argues, “but only a handful can train elite scientists.”1

 

Mary Talalay contributed to the reporting of this article.

 
 
 
 
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