An MBPhD programme in the UK: the UCL experience

History

Modern, science-based medicine can continue to deliver improved medical care and better outcomes only by effective research. Key to the prosecution of clinical research are investigators who are not only scientifically proficient but also clinicians. Such people have always been scarce. The dual training is lengthy and expensive; it is a minority interest among medical students.

In the UK and Europe, ‘physician scientists’ (medically qualified researchers) have traditionally trained by a well-trodden route in which individuals with a medical qualification (MBBS or MBChB in the UK) hold junior medical jobs until they achieve their postgraduate qualification (e.g. MRCP in the UK). After this, the individual breaks off into research aimed at a PhD qualification. Subsequently, the individual mixes research with further clinical training until the age of about 35, when he or she might be promoted to a senior research fellowship or a senior lectureship at consultant level. This pathway has served many people well and remains in common use to this day.

However, this process has its disadvantages. PhD completion rates for medically qualified graduates can be low, although the highly competitive and massively funded MRC fellowships are very successful (PM Stewart, P Maxwell, personal communication). The proportion of those embarking on PhDs after obtaining a postgraduate medical qualification who finally enter a true research career is not known. Before embarking on a career in science, doctors are already habituated in the loud, urgent, hurried ways of clinical medicine, which are different from those of careful, rigorous science.

In the 1950s, American universities, led by Case Western Reserve in Ohio, devised courses in which a PhD would be undertaken much earlier, while the students were still at medical school. The idea was to take clever and ambitious young people, give them an arduous, vacation-free training in both high-quality clinical medicine and rigorous science, and produce a highly trained individual who would be well placed to advance the boundaries of biomedical knowledge.

This and other early pilots were successful. In the 1960s, the US federal government began funding such programmes, generously covering the majority of the stipend, fees and extra expenses (such as healthcare) for the eight years that it took to complete the US programme. These ‘medical scientist training programs’ (MSTPs) are funded through the National Institute of General Medical Sciences at the National Institute of Health (NIH).¹

These American schemes have been outstandingly successful.^2–4 Entry is highly competitive; the contribution of US MDPhD graduates to medical research is by any measure very substantial. There are now about 75 MDPhD programmes in the US,⁵ of which 46 are federally funded.⁶

The UCL programme

The UCL MBPhD programme was started in 1994, shortly after another UK scheme at Cambridge.⁷ At UCL, the student is appointed during his or her BSc year. There is an abbreviated first clinical year that begins in July soon after the BSc exams. This lasts for six months, during which the student receives instruction on the basics of clinical medicine. In January following enrolment, the student embarks on their PhD research, which continues for either 2 years 9 months or (more commonly) three years nine months. After the PhD, the student returns to clinical studies until graduation two years later.

At UCL, PhDs can be undertaken at UCL itself, at the National Institute for Medical Research (NIMR) at Mill Hill or at the laboratories of Cancer Research UK (CRUK) in London. In exceptional circumstances, students can undertake PhDs outside these institutions.

During the PhD, clinical tuition continues, usually out of hours. Upon completion of their PhD, the student very often maintains contact with his or her PhD laboratory.

Neither of the major research funders in the UK (the Medical Research Council and the Wellcome Trust) fund these schemes directly. The clinical part of the course is funded by student loans and NHS bursaries (as is also the case for non-MBPhD clinical students), but the PhD (stipend, fees, some running expenses) is supported financially by charitable funds (see ‘Acknowledgements’).

Outcomes

We have enrolled a total of 107 students on to the UCL programme, of which 74 (70%) are men, a proportion that is reflected in both US and other European programmes.^8,9 Of these, 60 have now graduated as MBPhD. A further five have dropped out of the PhD and have graduated as MBBS only. One who dropped out of his PhD in the early years completed another PhD after graduating with his MBBS. Of the remaining students, 31 are currently in the PhD stage and 12 have finished their research time and are now in the later stages of their clinical studies.

The students have chosen PhD topics that reflect UCL's research strengths: 27% of the projects were (or are) in neuroscience, neurology or psychiatry; 20% in immunology or infection; 12% in oncology; 10% in cardiovascular medicine, 9% in development; and the remainder in other subject areas.

Of the 60 MBPhD graduates, most are in or intending to follow careers in some form of internal medicine. Eleven (17%) are in surgical training; there are two psychiatrists, three paediatricians and two clinical geneticists.

Of the 37 most senior students who enrolled in the period 1994–9 (graduating roughly between 2001–7, Table 1), we have two professors, one National Institute for Medical Research (NIMR) group leader (all appointed in their 30s), seven consultants and two Wellcome postdoctoral fellows. Three others have completed post-doctoral research.

Of the junior graduates who enrolled in the period 2000–5 (a total of 32, graduating in the years 2007–11, Table 2), more than half are in academic-type junior hospital positions (academic F1, academic F2 or academic clinical fellow (ACF)). One has a Wellcome postdoctoral MBPhD fellowship, another is a National Institute for Health Research (NIHR) Lecturer, another has a post-doctoral post in San Francisco.

It is invidious simply to count publications, but as of 7 April 2012, those who have been enrolled on the UCL MBPhD scheme have published 622 PubMed-accessible papers. These are listed in the ‘Supplementary information’ (available online). This list does not include book chapters and conference proceedings. A number of the publications have been of major significance in providing new insights into: the nature of Crohn's disease;¹⁰ the role of interleukin 6 in cardiovascular disease;¹¹ the role of coagulation factors in fibrosis;¹² the nature of diverse somatic mutations in cancer;¹³ fundamental aspects of pain;¹⁴ the possible complications of gene therapy;¹⁵ the role of the amygdala in amnesia;¹⁶ and gene silencing and infertility.¹⁷