Postgraduate degrees for rheumatology trainees: an options appraisal of MD, PhD and MSc degrees

C. Gordon, M. Salmon and on behalf of the BSR Research and Training Committee

Department of Rheumatology, Division of Immunity and Infection, The Medical School, The University of Birmingham, Edgbaston, Birmingham B15 2TT, UK

Correspondence to: C. Gordon.


    Introduction
 Top
 Introduction
 Which degree?
 So when should someone...
 Conclusion
 
A research degree is a passport to success. Well all right it is not, but over the last 15 yr or so, it has become the rule rather than the exception for rheumatology trainees to undertake a period of research during their specialist studies. This situation arose more from pragmatism (a lack of career grade posts) than any particular ideal. Unfortunately, for some the experience was unrewarding; usually as a result of undertaking unsuitable projects with inadequate facilities and poor (or no) supervision. However, many found that 2 or 3 yr spent learning a critical and analytical scientific approach greatly benefited their clinical skills when they eventually became consultants. A smaller number were bitten by the bug and pursued an academic research career. The key factors in determining success seem to be the right person doing the right degree in the right place at the right time.

Here we discuss the role and respective merits of different postgraduate degrees available to medical graduates and the timing of the research period, a factor that plays a significant part in the long-term success of the venture.


    Which degree?
 Top
 Introduction
 Which degree?
 So when should someone...
 Conclusion
 
MD
This has been the traditional research degree for most clinicians and usually requires about 2 yr of research to obtain the MD degree at the end. Although some people have spent a period of time in research because of a genuine interest in a research subject and training and have continued to be active in research thereafter, many are not so keen. Since the 1980s, the MD has been the passport to senior registrar posts, as many aspiring rheumatologists could not get into their chosen vocation when they wanted to due to a shortage of available posts. Spending time as a research fellow in clinical or laboratory-based research became an advantage when applying for senior registrar and consultant posts. However, although many did submit the research and were awarded a degree (with or without a viva), many individuals never actually submitted their research and got their posts on the `assumption' that they would submit and be awarded the degree in due course.

Traditionally, MD projects have been more clinically orientated than PhD projects, although this is not necessarily the case. Some MD studies are purely laboratory-based and some PhD projects are in clinical research. The value of MD research time both for the individual and for the body of scientific and medical knowledge has been extremely variable. Some projects have been well-thought out, supervised and successful both as training in scientific methodology and increasing understanding about certain subjects. Unfortunately, many projects have not been. Some people have spent 2 or even 3 yr `studying' a subject in a totally unproductive way, often with little or no guidance. Not infrequently the person was not really interested in doing the research anyway but saw it as a fast track to a good consultancy.

Many universities until recently did not require projects to be discussed with a supervisor nor require submission of the title for approval in advance of doing the work. Some individuals got very little advice during the project and when writing up, as the MD was often considered an unsupervised degree, although this has now changed in most universities. Needless to say the value of unsupervised work was often poor, certainly for training in scientific methods and the results were often unpublishable. Even more structured projects with a named active supervisor were not always successful, as not all supervisors have been adequately trained in relevant scientific methods and in how to train someone else in research techniques. If the trainee has obtained a peer-reviewed grant to fund the research this should not occur, but the problem is not necessarily avoided, and in the past many MD research projects have been funded out of `soft' money from pharmaceutical company trials. Thus, the trainee has not always obtained useful training, a justified degree and worthwhile publications. Even if the person does not get publishable results, it is to be hoped that they will have learnt something useful from the process of research and writing up a thesis that will be of value in their future career. After all, most become practising rheumatologists who will have little time for research thereafter, although some will be more academically minded and continue active research in the clinic and/or laboratory themselves or through collaboration. However, all rheumatologists need to be able to assess the literature and to decide whether and how to apply research developments to their clinical practice. Some understanding of research methodology and statistics is essential to do this properly.

PhD
This has become increasingly favoured as the research degree for all academically minded trainees over the last 10 yr. It is, however, often looked on less favourably by non-academic consultants in district general hospitals (as they may see PhD graduates as rather threatening superspecialists). PhDs have always been supervised (although with varying success) and usually take 3 yr to complete (sometimes more to write up and submit) compared with the 2 yr usually taken for MD research projects. In general they are laboratory-based research projects, but more clinically based PhDs are on the increase. They are more likely to be funded by peer-reviewed grants, to provide more structured research training and to be more `complete' and original research projects than MDs (the latter probably explains why funding is now easier to obtain for PhD rather than MD projects). However, in the UK, unlike many European countries and the USA, there is no requirement for formal teaching and course work during the PhD in most universities. Although supervised, the PhD trainee is expected to develop their research in a more original and independent manner than for MDs. After completing the PhD they should be able to plan future research effectively and be in a position to obtain further grant funding.

As with MD projects, the success of a PhD training programme depends on the personality, ability and commitment of the individual, as well as that of the supervisor and others in the research institution or elsewhere, who act as collaborators and advisors. These factors are usually more important than the details of the research project. The problems often lie in the difficulty of deciding whether 3 yr dedicated research in a fairly specialized area is what the trainee wants and needs for their future career, and whether the trainee is going to be suitable for the research work and training. The amount of research experience prior to a planned PhD is often very limited and neither the trainee nor the trainer may be sure at the outset. Moving between a PhD and MD, or vice versa, has become increasingly difficult, although some universities require a qualifying MPhil (short research thesis) at the end of the first year before allowing someone to register for a PhD, as a way of ensuring that they have the relevant skills. The timing of the PhD in the career structure is debatable but may be critical for the individual (see below). The amount of `routine' clinical work should be limited to one session per week in most cases and is usually arranged with local rheumatologists, even when the research project is undertaken in a basic science laboratory (e.g. immunology or biochemistry). This is sufficient to maintain clinical skills and may allow some exposure to different types of clinical practice than the trainee has experienced previously. This may promote increased awareness of the important questions in clinical medicine that require integration of basic and clinical science to answer.

MSc
This is a more structured postgraduate degree with less emphasis on doing research. The courses are very variable, some generic to a variety of medical specialities and some more specific for rheumatology. The courses are often modular, allowing some choice of subject matter, and include formal teaching and some independent course work for the trainees. This may include short research projects or dissertations. MSc courses are often undertaken part-time and are usually equivalent to a 1 yr postgraduate degree course. The emphasis of many of the MSc courses is to provide some background in research methodology and application of statistics, as well as more traditional topic teaching in specific diseases or the provision of health services. Some are designed to supplement the new Calman training schemes and others are more for doctors from abroad than for British graduates. Many have been set up recently as the new Calman training schemes for rheumatology have not included time for research thesis work (MD or PhD), and it appears that many future rheumatologists will have gone from general medical training at senior house officer (SHO) level, to rheumatology specialist registrar (SpR) posts and then consultant posts without obtaining any postgraduate degrees. It is not clear when people who want to do research will do it (see below), but for some who are wondering whether or not to take `time out' from the `normal' scheme, this may provide an opportunity to assess whether they like and are suited to more detailed study and research than the standard hospital training schemes provide (alternatively many may decide this `on the job' by getting involved in research projects). For others who definitely do not want to do much research but do want more comprehensive training or an opportunity to be different (and appear `better trained' on their CV or at interviews), the MSc provides a mechanism for achieving this without departing from the normal training scheme. The value of the MSc schemes is very debatable and has yet to be evaluated (not that formal evaluation of MD or PhD training has been undertaken, and there is known to be considerable variation in the quantity and quality of both as there are no standards).


    So when should someone do a postgraduate degree, if ever?
 Top
 Introduction
 Which degree?
 So when should someone...
 Conclusion
 
There are several points when these degrees have been proposed.

Integrate with undergraduate medical studies
This has been proposed for PhDs only, particularly for candidates who look like potential high-flying academics of the future. Most universities operate a system of combined BSc with medical studies for selected candidates (all at Oxford and Cambridge) and this is used to provide some introduction to more detailed study and research than a normal medical degree provides. Some universities offer a PhD place to those that do well in their BSc but some have now introduced PhD research programmes directly into the medical undergraduate course for selected individuals.

Advantages.
Early introduction to detailed research study: 1. may get the person involved at an early stage and commit to an academic career; 2. may prevent them getting bored with standard medical curriculum and from leaving before they find their niche; and 3. will provide valuable training in research methodology whatever the later career path of the individual.

Disadvantages.

  1. Individuals at this stage have too little experience to know what subject they will want to study long term and whether a PhD will be of any use to them in a medical career (and the value of a PhD in a different subject to that studied later is debatable).
  2. Without at least a BSc or equivalent first it may be very hard to tell if they are really suitable for this training, are likely to enjoy it and will put in the necessary commitment to make it a success in the short and long term.
  3. Even if they do well, they then have to go back to general medical training. This means that a lot of the research experience becomes lost/out of date, which is a particularly important point when the individuals try to apply for research funds later in their career. There is a risk that either they will not complete undergraduate or postgraduate medical training, or they will not come back to research.

After general medical training: after SHO posts and before SpR training
This applies equally to MD or PhD (funded by a fellowship grant or departmental funds as in the past) and could be a time for a full-time MSc, if funding was available (but this is unlikely so savings would have to be used or a fellowship obtained for study abroad).

Advantages.

  1. The individual is likely to have decided what branch of medicine interests them, thus to become involved in research at this stage may be very rewarding after a lot of general training.
  2. The post will `fill in time' usefully, while waiting for a SpR rotation post to become vacant. Experience in a relevant subject and contacts should then help to get the `much sort after' SpR post.
  3. This is similar to the old tradition of doing an MD before a senior registrar post.

Disadvantages.

  1. The individuals will not have worked in detail in rheumatology and therefore background knowledge will still be very patchy and limited (whereas in the past people had often done some registrar-level rheumatology before an MD or PhD project, prior to senior registrar training and/or academic appointment).
  2. The individuals may still not be clear about what subject will interest them for long-term study. Importantly, they will not know what the really interesting and important topics to study are, or who would be best to work with, in order to get the most out of the research training. (This applies to MD and PhD studies predominantly.)
  3. After a PhD (or MD) at this stage, there is still a need to complete SpR training in the chosen speciality if the individuals want to continue with clinical work. It is hard to combine continued research at postdoctoral level with clinical training, although attempts are being made to facilitate this in some places. However, both activities may suffer from not being done full-time. It is very difficult to obtain research funding if you are not fully active in research, although the recently introduced clinician scientist schemes are designed to help these individuals continue their academic careers (at this stage or, more likely, on completion of Calman training).
  4. It can be difficult to do general medical on-call at SpR level after a period of time out of medicine, but this is now frequently required in the first year of rheumatology SpR training.

As `time out' during SpR training
This applies predominantly to MD or PhD programmes; MSc studies are usually done in parallel with SpR posts and so much of this discussion is not relevant to MSc programmes.

Advantages.

  1. Trainees have more experience and can decide better what to study, who with, and can contribute to initial discussions on how to study the subject of interest.
  2. They are also more likely to get funding at this stage as a result, and are more likely to be sufficiently committed to the subject to put in the time required to do it and be successful.
  3. Individuals are more likely to remain active in the field and therefore to continue to get grant funding as required in the future (particularly relevant to individuals who obtain a PhD and wish to continue in academic posts).

Disadvantages.

  1. SpR training still has to be completed with the above problems for clinical and research activities (in general, worse the earlier in the training programme the research is done, with the exception of medical on-call if that is no longer required on return to the SpR scheme in rheumatology—the problem will persist if dual accreditation in medicine and rheumatology is sought, but this is unusual in academic rheumatologists).
  2. Two or 3 yr out of a clinical training programme may cause problems with rotations, and return to an individual's original scheme may not be guaranteed.
  3. The cut in pay by missing out on `on-call' payments may put people off (but it may be possible to be included depending on local arrangements) or individuals may do locums (but research may suffer as a result).

After SpR training has been completed
This particularly applies to MD/PhD programmes and some comments apply to MSc courses.

Advantages.

  1. This option avoids problems with remaining active in research while finishing clinical training. The individual should have less problems obtaining further research funds after completion of the research degree, providing that the project goes well and results in publications.
  2. Individuals might find this a useful way of filling in time while waiting for a consultant post and the research should enhance their CV. The question of whether or not to continue with research, and how much, in the future is left open and may depend on the post finally obtained. The post sought by an individual may itself depend on the research experience obtained.
  3. As individuals will have the most background in the subject by this stage, they should be able to get the most out of the research opportunity.

Disadvantages.

  1. Individuals might worry about missing a `suitable' consultant post, but the starting date may be negotiable.
  2. This option will reduce clinical work experience immediately prior to taking up consultant responsibilities which might be seen as a disadvantage by some.
  3. Traditionally research fellowships are less well paid than clinical training posts, as there are no on-call payments. This means that people may be reluctant to take a considerable cut in salary just at the time when they would otherwise get promotion and a pay increase, and they may well have children to look after and other financial responsibilities making this option difficult.
  4. By delaying research so long, aptitude for original research and thought may have been lost in some individuals, depending on their earlier training environment.


    Conclusion
 Top
 Introduction
 Which degree?
 So when should someone...
 Conclusion
 
Everyone should have at least some training in research methodology and statistics to aid understanding of published research papers, preferably as part of standard Calman training. This is essential for good clinical practice. Not all rheumatology trainees want or need to spend 2 or more years doing research but for someone with definite research interests and academic ability, a PhD is likely to be better than an MD. There is no right time to do research and the best time to do it will probably depend on the individual and the institution. Later is likely to be better than earlier in our opinion, that is: more successful and more rewarding during, or after, SpR training, rather than earlier. An MD provides a useful research opportunity for those who are less sure of an academic career but who want a period of time in clinically related research and a degree to show for it afterwards. Like PhD studies, the MD research project should be carefully planned in advance and supervised by an appropriately trained person in a stimulating environment, where relevant support is available or can be arranged (for example, statistical advice). The quality of the individual and the research achieved will determine the future career of the trainee more than the name of the degree they obtain (MD or PhD). MSc degrees may provide an introduction to research methodology but are not comparable to MD/PhD research degrees and are likely to be done by some people instead of, or before, a research degree. They are not likely to make much impact on the long-term career of an individual on their own.

Submitted 25 February 1999; revised version accepted 23 April 1999.