Saturday, July 26, 2008

Clarity and Opacity

I have a habit of declaring that moments in life offer clarity and re-invigorate (and re-define) the purpose behind what I do. Take, for example, my relationships: a series of dates, phone calls, e-mails, and then finally "what are we?" discussions lead to relationship bliss - the moments culminate to define The Relationship as it is. Or in MSTP training: good exam scores, successful grant applications, exciting results in lab, engaging clinical experiences might lead one to say The Career is a purpose-driven existence as a physician scientist.

But what if all along - instead of clarifying or defining - the milestones and the progress actually mean more questions rather than answers? What if tension builds rather than resolves?

I find this happening to me quite regularly. On one hand, things have been going pretty well -- I made it through the first two years of medical school without any major problems, the boards (at least step 1) is done and I passed, research has started (I'm learning new techniques, trouble shooting, etc) and I am funded for grad school (very lucky to have gotten an NRSA)...and I've managed to do a little bit of work in the clinic. So all-in-all, this sounds like The Career scenario above. Except that I don't feel like anything is really clarified. Rather, I see my future as quite unknown. Industry, consulting, purely clinical, purely research, policy, NIH, ahhh! I really have no clue what I will end up settling on for a career.

I think part of this dilemma (and total lack of vision for the future) stems from the nature of the first two years of the MSTP. On one hand, we are consistently medical students for the first two years. On the other hand, our program directors (and our desire to enter the PhD phase of the program with some obvious direction) require that we start thinking about our research goals; i.e. with whom will we rotate, into which program will we enter, and so on...So it's hard to firmly decide. We straddle the fence.



And now in the PhD phase, while it is tempting to completely immerse myself in research, I find myself inexorably drawn to the clinic for work every other week. Although it's for just one morning or afternoon, the experience re-affirms for me the uniqueness of my training plan. To not do this, in my mind, would be heresy; let's face it, we're doing these programs because we believe in the (tantalizing) possibility of translational research. How can we firmly believe in that if we're unable to give up two mornings or two afternoons each month to brush up on our clinical skills?



Indeed I have found my clinical experiences - interspersed within the beginnings of my research training - to be engaging and vital to my perspective on being a physician-scientist. But just as I have lacked clarity to this point, so do such experiences perpetuate the inevitability of opacity as status quo for the MSTP trainee.

Saturday, July 19, 2008

Open-ended

Note: this post is part fiction, part non-fiction; interpret as you please.


Q—

A— I’m doing well, thanks. Yourself?

Q—

A— That’s good. Well, first year of medical school, I’m excited, yes. It starts August fourth.

Q—

A— I’m not sure. I guess in high school the interests started to form, but I’d rather not rattle of my personal statement. I do remember, though, being placed on the medicine or science track by my high school teachers and advisors.

Q—

A— I don’t want to use the word with a negative connotation. The idea behind track is complicated, and I’m currently struggling with it. In any case, I’m fortunate to have received that type of attention in high school. I was privileged, and I was-slash-still-am naïve.

Q—

A— I was particularly naïve coming out of high school because I had a lot of expectations of college. You know how it goes. It’s been clichéd in a gazillion trashy teen movies and novels. Not that I’ve been exposed to any of this.

Q—

A— An example? Well it’s simple. I though college was about the individual. I thought college was about me, about what I would gain. I thought I would be a sponge, only a sponge. People would feed me, and I would grow without a saturation point. My carrying capacity was supposedly infinitely large, a natural wonder.

Q—

A— Are you making fun of me?

Q—

A—It wasn’t completely my fault. High-school counselors, teachers, peers, literature enabled the creation of a place, College, where the Emersons, the Individuals, created things bigger than themselves.

Q—

A— Entering college I expected of expectations. I was confused, had no idea about what the next four year entailed, so I made things up. The expectations were formed by ill-informed conceptions, filtered and collected by someone who didn’t have an accurate description of reality. Because I didn’t really know what to expect, I formed new expectations, and from these expectations I expected new things, new ideas. I was day dreaming, falling into a recursive trap.

Q—

A— I know I’m being vague and abstract.

Q—

A— So what happened in college? What really happened is I-did-not-suffocate-the-universe-with-my-immensity-because-I learned-that-college-was-not-about-the-College-or-the-Individual. I went to college for a liberal arts education, and I took courses that interested me, and then, thanks to friends, advisors, professors, and mentors, I was given incredible opportunities that started me on the MD-PhD track.

Q—

A—The Emerson-ian-half of Anthony did not like tracks. Tracks specialized my education, thus preventing the formation of a black hole. The realistic-half of Anthony understood that track were a good fit and provided a lot of opportunity, a crap-load, some might say. But it is important to note that the Anthony-of-the-past created a dichotomy between the tracked and un-tracked self.

Q—

A— The answer to that question is way above me. Ask someone else.

Q—

A— The bottom line is that this self is very privileged. Throughout my life, my parents, my friends, my acquaintances have fulfilled themselves by fulfilling me, and now it’s my time to fulfill others. I’m not totally ready yet, but I’m getting there.

Q—

A— Yes. I think medical school will be a nice step forward. I know I will have people to trust and people can trust in me. The support will be there, not just for me, for everyone. I’ve already volunteered myself. Outside of what I just said, I don’t know. I don’t know what the next eight years of my life will entail. I don’t know what to expect, and I don’t want to expect, for reasons you’ve weaseled out of me.

Q—

A— So, long story short, I’m ready to start medical school. I’m excited to start medical school. Along with all this excitement, though, follows some anxiety. Anxiety that stems from the excitement of so many opportunities and resources placed in front of me. An anxiety that is a bedfellow with expectations, because in part the anxiety is an expectation, and I don’t want to believe it is true.

Q—

A— I’d rather not talk about it now. I guess it’s something I’m going to have to find out sooner or later.

Monday, July 14, 2008

The applicant creates an application, which is then digested by a committee and reconstructed back into an applicant (whew!)

I decided not to do a summer rotation. Instead I spent a month and a half traveling around Spain, taking some classes, doing touristy-related things, and working on a farm/garden for a week. This was the right choice for me—I needed a break, needed some time to unwind, forget about academics, decompress from thesis, the interview process, etc., etc.

It has been five months since my last MSTP interview, and I am glad the process is over. At this time last year I was thinking about my secondaries but not filling them out, instead concentrating on summer research. I watched as the number of forms- and essays-to-be-completed added up, reaching 15. I waited and waited until I achieved an appropriate headspace, after finishing my summer work, and resumed the application process, which lasted way too long when final decisions were sent out in middle March.

Now that I’m a veterano, experienced in the ways of interview gaffes, I’ll share my opinion regarding the application process. My opinion is pessimistic. My opinion is jaded. Whatever.

The key to the application process is to think like a car salesman, a damned good one, so good that she can write and speak about herself in a way that is seamlessly authentic, an anti-car-salesman, but because the illusion of authenticity is manufacture, in essence, the best applicant is the anti-anti-car-salesman. Enough with the meta-jiberish—I’ll save it for later.

The applicant needs to separate herself from others, create hype about her potential, and promote herself as a worthy INVESTMENT to the medical-scientist community. That being said, absurd stats (MCAT, GPA, # of pubs, etc.) are nice but not necessary because LOR’s, and personal statements and experience are equally important, and not quantitative. With that said, I can think of two rough tiers of assessment in the application process. (Feel free to add more factors that I’m forgetting.)

Tier One: MCAT, grades, LOR’s, personal statement, research experience

Tier Two: number of publications, clinical hours, extracurricular

The application selection process is complex. I have no idea what goes on behind the scenes. I could speculate about formulas to achieving interviews and acceptances, but I won’t. What I will say is, be smart with your words, tie your narrative with your career goals, be the anti-anti-car-salesman. But N.B., the anti-anti-car-salesman (okay, now for an invented acronym: aacs) is not bad. The aacs is genuinely interested in a career as a medical-scientist. The aacs is passionate about research and medicine, and wants to contribute to society. The aacs is confident, has a sense of direction, a career trajectory, and can create links between basic science and translation research. Often the aacs is so good that they have even fooled themselves.

Anyway, I have digressed into potentially worthless metaphor, but if I can give one piece of advice, the ideal applicant will create an application that constructs an applicant, perceived by the individual reader and collective committee, with confidence, passion, and sense of service. The applicant should be a master of words.

I think I have given myself a headache now, so I am signing off for now. I may post soon about my thoughts regarding the start of MS1 (August 4th!).

Monday, July 07, 2008

Q and A, part 2

Another question from a visitor to this blog:

I've a few questions about the MSTP program. More specifically, how your application process went. I'm wondering what sort of laboratory/clinical experience you had before applying to your program? What were your MCAT scores? Also what did you study in your undergraduate years?

I'll start with the quicker stuff first.

In terms of MCAT scores, I'm happy to give a range of scores (it's not really necessary to give individual scores, because everyone is different and the test will be different than it was in 2005 in terms of average scores, etc). Of the people I know in the program (including me) here are some scores:

34, 37, 36, 38

(I don't include writing because I'm not sure a single person remembers his or her writing scores...and people, especially MSTP folks, really don't care much about it).

My research experience began the summer after my freshman year and continued until I graduated. (I went to Pomona College in Claremont, California - Pomona is a small liberal arts college with active researchers in Biology, Chemistry, Physics, and Mathematics; I was a Chemistry major with a Biochemistry emphasis - there was no Biochemistry major when I attended Pomona). To be honest (because on applications it is easy to claim continuity of research) I probably worked an average of a day every other week during the year and then ~10 weeks during the summers; however, I worked in spurts, so some really meaningful experiments and results were still performed and obtained, respectively, during the years. I was fortunate to be funded as a researcher starting after freshman year - I wasn't a tech or a dishwasher, so I had a project of sorts early on, and it developed into a story that comprised two publications and a senior thesis.

I think there's a major take-home about my research experience: I could discuss my research formally and informally early on because I had a project I was invested in from the start. And so, when it came time to interview for MSTPs when I was a senior, it was second nature to talk about research. For the most, this helped me during my interviews. That said, I had a rocky start with interviews (UCSF, for example; though I would say some of that had to do with getting interviews with 'difficult' individuals, to put it nicely). So I would suggest getting your story straight - figure out how to explain the experiments you did, the background/motivation behind the work you did, where it fits into an interest in medicine, and what you see yourself doing in the future. There are no correct answers in this, but earnest and well-informed ones are rewarded with thick acceptance packets in March or April.

Don't let the fact that I (or others) have done quite a bit of research discourage individuals who have spent less time in a lab -- your commitment to a project, grasp of the subject matter, performance in classes, and letter from PI can all help if the amount of time is lacking. And if you feel you're not quite there with your research experience, by all means consider taking a year off. (In any event, admissions committees will want to know what you did if it wasn't research. If you were still trying to find your passions, and research is what you landed at, taking more time is never a bad thing).

As I said above, I was a Chemistry major at Pomona; thus I took a variety of classes related to my major (calculus series, physics, Gen Chem, O-chem, P-chem, P-chem lab, Analytical Lab, Biochem, Bio-organic chem, Analytical chem, NMR spectroscopy, senior thesis, independent study) and those for biology/med school (Genetics, Cell and molecular biology - this is a misnomer, as Pomona's intro course has now been correctly re-named cell biology and cell chemistry; and DNA repair and human disease. Being that Pomona is a liberal arts college, I also studied some classics (greek literature, lower levels), art history, music (I played in the orchestra throughout my time at Pomona and studied in the music department on solo and chamber music), shakespeare. I'm not rattling this off to be impressive - most Pomona students do this and more (there is a bit of a grade inflation problem at the school) - but instead to say that people (read: MSTP admissions committees) like this kind of diversity in courses, with also a clear commitment to some major - which doesn't necessarily have to be science. Case in point, a soon-to-be second year in the UCLA MSTP was once-upon-a-time a humanities major at a small liberal arts college. She did post-bac work, research at the NIH, and now is passionate about becoming a physician-scientist.

I spent about 2 months at the Pomona Valley Hospital doing one evening a week of bed changing, patient escorting, and other mindless tasks. But I got a sniff of medicine, and I liked what I was sniffing. My most exciting moment there, incidentally, was as a patient with a subluxated (a.k.a. dislocated) knee-cap.

Ahhhh - the application process. I'm not sure where to start. I think the short answer is that when I started my application, I felt like I really believed in being a physician-scientist, and so answering questions that asked me to expound on my belief in research and medicine weren't that difficult. It didn't hurt that I was forced out of physical activity for a month after the knee injury. I will try to add some other thoughts about the application process in more detail in a later post; for now, I seek some R and R before a busy day in lab tomorrow.

Friday, July 04, 2008

Q and A

In the previous post, an anonymous reader posted the following question:

There are a lot of people applying for this program for the wrong reasons, like top residency, free medical school and etc... What do you have to say to those that lack the passion to do translational research?



I agree that many people do apply for MSTPs for the wrong reasons; it's also true that people apply to medical school alone, law school, podiatry school, dental school, graduate school, and so on for the wrong reasons. In the case of MSTP students doing so, I have a feeling the decision comes back to haunt them. The problem is this: 1) either you enter such a program, realize the research isn't for you, and then opt out after two years or 2) you go forward with graduate training knowing all along that research isn't for you. Both cases are undesirable. In the first case (two free years of medical school), a big reason for why you were admitted to medical school was that you were an MSTP student, hoping to do research and receive clinical training. If that goes away, what remains? Clearly, if a student had not dropped out before then end of second year of medical school, then research rotations had to have been done; and if this were the case, what does such a student tell residency directors asking what they did for the time between years one and two? "Uh, I was in the MSTP and decided it wasn't for me..." -- that has to be about the opposite of the supposed "MSTP boost" that MD/PhD students are known to benefit from on their residency applications. So while it could be a little bit harmful, the major consequence of dropping out of the dual degree program is the lack of benefit from research training and the distinction it provides you in contrast with the rest of your medical school colleagues.

In the second example (going forward with research with no intention to do it one day), the draw-back is personal and the suffering can be immense. Graduate school - as I am beginning to realize - can be approached from many different angles, and effort varies across a wide, wide spectrum. Poor effort generally means a long PhD, and I would venture to guess it is more common in students who really didn't want to do a PhD in the first place (but liked the idea of having two degrees after their names)
. I can say that I've done the math, and for individuals who choose to suffer through the PhD just for the sake of it, MSTP is not more beneficial financially even in the short-term after medical training is complete. A short time in a middle-of-the-road paying sub-specialty (presumably) outside of academia (since these people sort of swear off research after residency) will make up most of the difference that staying in the MSTP would have offered.

Alas, I'm not exactly answering the question. In the two above cases, I argue that it just doesn't much make sense to be in an MSTP for the more superficial and/or personal suffering reasons. But what to say to someone who lacks a passion for translational research?

I think that is a difficult question. The cynical response to the question would be that a person lacking a passion for translation research is a realist. In many fields, the true promise of translational research is far from reality, and so the absence of "passion" could be a recognition of a lack of feasibility in many areas. On the other hand, a more idealistic response would be this: the future (and don't ask me when, I'm like John McCain on this one, I don't do timetables) of medicine will be translational (read: stem cells, genomic/proteomic medicine...) and to not have some kind of passion is like fatally dooming a career before it starts...or something like that.

More than likely, what I would say to a person lacking a "passion" (and we'll say for research, translational or otherwise) is this: this program is not for you, and figuring it out sooner rather than later will be of great benefit to your career.

This is, of course, not to say that one must have a vision of the future well mapped out prior to entering medical school. In fact, as long as there is some passion for research, the rest can figure itself out. In my case, I find the future to be wide open. I knew I wanted research training, and I felt that there was no way I could have decided between straight medical school and a straight PhD program. Somehow, I will connect the passion for the two together, even though I haven't figured out a plan at this point. So maybe I'll go to an internal medicine + sub-specialty fellowship into postdoc and then look for positions in academics. Or maybe I'll go the surgery route and find ways to be more of a collaborator with persons solely dedicated to research. Or maybe I'll go to residency and then consult for biotechnology companies. Or whatever. The point in this case is that I couldn't imagine my life at this point without medicine or without research. Both are a part of who I am.

I should also add that in today's funding environment of the NIH - shitty - it doesn't hurt to have a researcher's best insurance policy, an MD; when people in my lab/department first mentioned it, I thought they were joking - always poking fun at the med students. But then I realized they weren't kidding. People are getting royally screwed right now because the NIH budget was slashed so that we could (warning: irrational half sentence rant to follow) go fight some stupid war in the middle east. People who have been funded for more than a quarter century on the same R01's not getting the easy renewals they once did, and there has been quite a shake-up in academia. Not to say that there aren't options for straight PhDs, but making it isn't easy and might take post-doc'ing and slave laboring in graduate school that rivals the length and effort involved in obtaining a dual degree. Oh yeah, and medicine is kind of screwed as well. Although some say it's doomed, I would say it's just entering a long and awkward phase of puberty. It's growing male breasts right now, has acne and spotty facial hair, and it gets irrationally upset and needs large amounts of sleep and its experimenting with masturbation (it's kind of screwing itself right now). Being a professional in medicine, research, or both will be better in the future; when that is, and how it manifests, who can say? But I'm glad to be in both.

Tuesday, July 01, 2008

New beginnings...

As a first year PhD student, I'm close to being smack-dab in the middle of our program. So it's with some sense of surprise that I got the following recently:

"...On behalf of UCLA, I'm extending an official offer of admission to the Graduate Division. You have been singled out from a pool of exceptionally qualified and talented applicants in a rigorous and highly competitive process. Your selection recognizes your academic accomplishments and potential for advanced scholarship. Let me add my personal congratulations to those of your family and friends..."

It turns out that when we go from the first two years of medical school into graduate school, we have to "apply" to our graduate programs. It's sort of fun to get letters like these when you did nothing but fill out some online forms stating your date of birth, city of origin, country of citizenship, etc...I suppose I could rant about how these form letters cheapen the meaning of such an acceptance to a person who was actually waiting for it, but whatever, there's no need.

I will continue some of my boards thoughts and offer some perspectives about the transition to graduate training when I finish the back-log of laundry I have at the moment.

Good luck to all incoming first years and folks applying at the moment!