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Medical & Graduate Training

Students

The MD-PhD Program receives ~450 external applications for admission to the program annually, as well as applications from a small number of current 1st, 2nd or 3rd year medical students and 1st year PhD students who develop an interest in career trajectories that benefit from dual-degree training. These applicants are academically excellent and demonstrate significant experience and success in research. We have an increasing diversity of matriculated students along axes of race/ethnicity, geography, socioeconomic status and undergraduate institution, the result of intentional changes in recruiting and admissions practices over the past 5 years.

The table highlights the schools/departments that actively participate in MD-PhD student training as a result of ongoing communication and collaboration between Dr. Kazmierczak and her team of Associate Directors with the leadership of these departments and their many Directors of Graduate Studies (DGSs). The faculty within these departments and programs are committed to mentoring both PhD and MD-PhD predoctoral and postdoctoral trainees and participate in a number of federally-funded institutional research training programs.

Participating Medical and Research Training Entities

MD-PhD training is supported by multiple professional schools at Yale, as well as the Graduate School of Arts and Sciences (GSAS). Our MD-PhD program has strong relationships with leaders and faculty in each school, allowing our students to take advantage of the strengths of our diverse faculty.

1) Biological and Biomedical Sciences (BBS) Program at Yale School of Medicine. This PhD umbrella program encompasses 10 departments and the Interdepartmental Neuroscience Program (INP) based at three interconnected campuses: the Medical School, Science Hill and West Campus. Most current students have affiliated with a BBS department.

2) Yale School of Public Health. Around 10% of our current students have affiliated with PhD-granting departments in YSPH, which include Epidemiology of Microbial Diseases; Biostatistics; Chronic Disease Epidemiology; Environmental Health Sciences; Health Policy & Management.

3) Yale School of Engineering and Applied Sciences. Twelve current MD-PhD students have affiliated with the Biomedical Engineering program.

4) Yale GSAS. MD-PhD students have affiliated with the following “non-traditional” departments over the past decade: History of Science/History of Medicine, Anthropology, Social Sciences, Applied Mathematics, and Religious Studies.

5) Yale School of Medicine (YSM). Our LCME-accredited medical school opened in 1813, adopted its MD student thesis requirement in 1839, admitted its first female students in 1916, and currently provides preclinical and clinical training to all MD-PhD students at Yale. Each entering class of 104 medical students includes ~20 MD-PhD trainees, who participate in the 18-month pre-clinical curriculum and first two clerkship blocks (3 months each) side-by-side with their entering class.

Clinical Training Entities

1) Yale New Haven Hospital (YNHH). YNHH serves as the primary teaching hospital for MD-PhD students. This non-profit tertiary care center has 1,541 beds at two campuses in downtown New Haven, York Street and St. Raphael, and encompasses the Smilow Cancer Hospital at YNHH, YNHH Children’s Hospital and YNHH Psychiatric Hospital. 1.5 million outpatient encounters were recorded in 2017 at YNHH.

2) VA Connecticut Health Care System in West Haven provides a core training site (inpatient and outpatient) for YSM medical students, residents and fellows.

3) Yale School of Nursing and Physician Assistant Programs. Students in the PA program and the nursing school train with 1st year medical students as part of the Interprofessional Longitudinal Clinical Experience (ILCE). The ILCE teams utilize clinical sites at YNHH and at southeastern Connecticut sites that belong to the Yale Affiliated Hospital Program, namely Bridgeport, Danbury, Greenwich, Griffin, Norwalk, St. Mary’s and Waterbury Hospitals.

Training Faculty

Yale School of Medicine is home to 1,617 ladder-track faculty, many of whom are committed to training pre- and postdoctoral scientists and physician-scientists. Our roster of 110 participating faculty on our MSTP training grant is composed primarily of trainers who are current or recent mentors of MD-PhD students. These individuals represent faculty at all ranks (12 Assistant, 28 Associate and 70 Full Professors); 32 (29%) are women. Physician-scientists are well-represented, with 15% MD and 25% MD-PhD faculty on our roster. Many (49 of the 110) have primary appointments in clinical departments and remain clinically active while directing productive and well-funded research programs. All MD-PhD faculty are committed to student mentoring and have completed an 8-hour mentor training curriculum modeled on the National Research Mentoring Network (NRMN) curriculum.

Specific Required Elements of Dual-Degree Training and Evaluation

Medical School

Preclinical Medical School Curriculum. The current preclinical curriculum was introduced in 2015, after a 5-year process of re-examination of curricular content by multiple medical school committees. The content of the preclinical curriculum was re-organized and now follows a “systems” based approach. Multiple “threads” (including basic science, pathology/pathophysiology, anatomy, public health, and epidemiology/biostats) carry through the 18-month curriculum longitudinally. Teaching formats have been diversified, based on literature that supports the efficacy of flipped classrooms, team-based learning, and experiential learning. Student and instructor feedback guide revisions and improvements to the curriculum, with many surveys focused on ensuring that important content was covered in the curriculum while avoiding redundancy. Although Yale does not give grades for medical coursework in the pre-clinical curriculum, with the exception of certain courses taken by MD-PhD students for graduate credit, students take regular self-assessments to measure and guide learning and must pass “qualifier” exams in each subject area. Scores on these exams are revealed only to students, unless the student fails. In this case, the student must remediate with the instructor in the subject area and achieve a passing grade on the qualifier.

Interprofessional Longitudinal Clinical Experience/Medical Coaching Experience. Clinical skills are taught to MD and MD-PhD students from the start of medical school and practiced in small groups that also include physician assistant and nursing students (ILCE). Beginning in April of Year 1, medical students receive coaching in groups of 4 on history taking and clinical exam skills. Student learning of clinical skills is assessed by standardized assessment of history-taking and clinical exam skills (C-OSCE 2) prior to start of clerkships.

Integrated Clinical Clerkships. Restructured clinical clerkships were introduced in 2014. Four 12-week blocks integrate related clinical disciplines and provide unified coursework that covers common clinical and basic science material. A “Precede” includes a clinical skill boot camp, while a “Postcede” consolidates learning and provides opportunity for reflection (“Power Hour”). MD-PhD students usually complete the “Medical Approach to the Patient” block (Internal Medicine & Neurology) in Y2, as this allows them to participate in longitudinal clinical electives during the PhD years. They also complete a second clerkship, choosing from “Surgical Approach to the Patient” (Emergency Medicine & Surgery), “Women and Children’s Health” (OB-Gyn & Pediatrics), and “Biopsychosocial Approach to Health” (Psychiatry, Ambulatory Medicine). (Appendix 1A: YSM Integrated Course Curriculum). Students receive grades and evaluative comments from clinical preceptors that are included in their Medical Student Performance Evaluation (MSPE). Students are anonymously surveyed about the learning environment on the wards, and all reports of bias or abuse toward student trainees are discussed with the clerkship director and addressed, e.g. by education of supervising attendings and housestaff. Student learning is assessed by USMLE Step 2 CK/CS exams and performance on the standardized assessment of history taking and physical exam (C-OSCE 4), and students must pass these exams in order to graduate.

Capstone Course. This 3-week required course in the final year of medical school focuses on internship-readiness for graduating students. Specialty “boot camps” reinforce clinical and technical skills.

Graduate School

Coursework and Teaching. Each PhD department or program that trains MD-PhD students has established course and teaching requirements for dual-degree students. Students must obtain “Honors” grades in two graduate school courses before admission to candidacy.

Qualifying Exam. Each PhD department requires students to pass an area exam or qualifying exam; the process is department-specific and described in Yale Graduate School’s Programs and Policies Bulletin. The student is admitted to candidacy when they pass the qualifying exam and submit their dissertation prospectus, normally at the end of Year 4 in the program. The MD-PhD program has incorporated additional training and assessment of rigor and reproducibility at the time of the qualifying exam.

Thesis Committee. MD-PhD students follow department specific rules to convene their thesis committee. In addition, a MD-PhD Director joins the committee to monitor student progress, provide information about unique aspects of dual-degree training, and help coordinate completion of PhD requirements with the process of re-entry to the wards. This, along with twice-annual committee meetings, helps our students in several ways: it identifies potential problems with project or advisor early; it provides additional mentoring/oversight that improves retention in training and progress toward degree; it helps students and faculty focus on training goals unique to MD-PhD students, e.g. the need to integrate the re-entry timeline with completion of PhD requirements. The committee meets separately with the student and advisor at the start of each meeting, so that any concerns can be shared openly. Committee meetings are guided by a formal “report” form, which includes consideration of the student’s career objectives and Individual Development Plan (see below). This form is signed by the advisor and committee members, reviewed with the student, and submitted to the departmental DGS.

Dissertation Progress Report. Each student submits an annual progress report to the Graduate School that must be reviewed and signed by both advisor and DGS; this report is also shared with the MD-PhD Director. D5. Dissertation Defense and Publications. Each department has specific requirements for graduation. In addition, the MD-PhD program requires (1) that the dissertation be submitted and successfully defended and (2) that a 1st author manuscript be submitted before the student can resume clinical training.

Requirements Unique to MD-PhD Students

Individual Development Plan (IDP). In 2014, a committee of MD-PhD students constructed an IDP instrument, based on examples from other dual-degree programs and with iterative input from the student body. Beginning in Fall 2014, all students complete the IDP annually and review their career and training goals for the coming year, as well as their progress towards these goals, with the Program Director(1st year students and graduating students), the Associate Director who is their MD-PhD academic advisor (2nd through penultimate year), or the Associate Director for Clinical Education (penultimate “re-entry” year). The IDP review monitors student progress, identifies areas in which a student can benefit from additional advisors or mentors, and allows a student to re-evaluate their personal and professional goals throughout the training period.

Responsible Conduct of Research. Training in Responsible Conduct of Research is required of all MD-PhD students in their 1st year in the program and again in Year 5. Mentor training, required of all participating faculty, makes clear the expectation that responsible conduct of research is to be discussed regularly within the laboratory with trainees.

Annual Retreat. The mandatory annual retreat for MD-PhD students has undergone several changes over past years to emphasize its role in MD-PhD community building and career development. In its current form, this overnight event occurs early in the academic year and intentionally focuses on bringing younger and older students together. The retreat always includes events that highlight student research (in 2018, a “pitch-slam” research talk competition involving all students as presenters or judges), career choices and/or work-life balance (usually a panel discussion featuring MD-PhDs), near-peer mentoring (in 2018, focused on “transitions” into the lab, back to the wards, and into residency/postdoc training) and programmatic priorities (presented by the Student Council, Council on Diversity and Inclusion, and Directors). The Folkers Lecture is usually delivered as part of the retreat and features an inspiring physician-scientist (in 2018, Helena Hansen MD’05, PhD’05, Assoc Prof of Psychiatry, NYU). A student committee programs the Retreat with faculty assistance, and students are surveyed after the retreat.

Science at the Frontiers of Medicine (CB600/601). “Science at the Frontiers of Medicine” is a full-year (32 week) course for first-year MD-PhD students that meets weekly for 1.5 hours. The course focuses on the science that underlies medical practice and follows the progression of topics in the 18-month pre-clinical medical school curriculum. This course serves as a first introduction to the principles of rigor and reproducibility for MD-PhD trainees. The varied expertise and prior knowledge of each of our ~20 incoming MD-PhD students challenges us to design a curriculum that engages each student while providing a framework for how to evaluate experimental design, scientific techniques, analytical approaches, data reporting and research conduct. Ongoing, iterative changes have ensured that the course allows students to master key fundamental skills that can be applied to the conduct their own research.

Research Rotations and Affiliation with Laboratory and Advisor. MD-PhD students are required to complete 2-3 research rotations, which usually occur after the 1st year of medical school.

Research in Progress (RIP). All students present their PhD research in a specific MD-PhD RIP forum 1-3 times during training. RIP talks have several purposes. They allow student speakers to learn how to present their research to a knowledgeable but non-expert audience in a 15-20 minute format; they allow students to learn about ongoing research, and potential projects or collaborations; they provide formal feedback to speakers from students and faculty in the audience via a formal survey instrument. Directors attend these monthly RIP talks and provide feedback to each speaker. Dinner is provided at RIP, making this a social as well as scientific programmatic event.

Lab-to-Wards Transition and Re-Entry Elective. All students in Year 5 or later of the program attend a mandatory spring meeting outlining the timeline and requirements for returning to the wards. At that time and semiannually thereafter, students answer a questionnaire about their anticipated timeline for returning to the wards, which guides the process of re-credentialing students and scheduling their clerkships. The MD-PhD program offers a 2-week immersion "Re-entry" elective to refresh in-patient clinical skills. These electives are on an internal medicine service led by an attending and house-staff team or an attending hospitalist team at the student's choice of our three medical campuses. The grade is pass/fail. The student is given elective credit and an evaluation is prepared by the precepting attending. The student may also solicit evaluations from residents. The student evaluates the attending and the elective at completion. Most students take these electives immediately following their defense in the month prior to returning to clinical medicine. This is a mandatory elective for student who have not had patient contact for more than one year prior to formal re-entry into clinical medicine and is taken by most students as a useful and stress-reducing re-introduction to the inpatient environment.

Curriculum in Leadership and Research Management for Physician-Scientists. Career development workshops and trainings that have been offered to MD-PhD students over the past years are now restructured into a formal curriculum with required modules in “Teaching”, “Mentoring” and “Proposal Development”, and elective modules in “Communication”, “Leadership & Teamwork”, “Self-Management” and “Research Management”. Students will be required to complete one elective and 3 required modules, each of which will include an experiential component. Any student who completes all seven modules will receive a Certificate in Leadership and Research Management.

Education

Integrated Curriculum

MD and PhD training are highly integrated throughout a student’s time at Yale. From the outset, MD-PhD specific courses within the pre-clinical curriculum focus on developing a physician-scientist identity in students. Opportunities to continue clinical practice while in graduate school enrich students’ understanding of physician-scientist careers. MD-PhD Program retreats, research seminars, and career development workshops and courses develop personal and professional skills specific to careers that bridge the clinic and laboratory.

Becoming a physician-scientist goes beyond completing medical school and graduate school; it’s about the life-long process of learning how to see limitations in clinical knowledge and practice as opportunities for discovery and learning. Our goal is train students to see the connections between clinical practice and research, and to teach them the professional skills needed to join these realms of clinical practice and research in their careers as physician-scientists.

Instruction in Rigor and Reproducibility

The teaching and practice of the principles that underlie high-quality research through the explicit inclusion of training in scientific rigor and reproducibility occurs at multiple phases of MD-PhD training. Each student’s ability to critically assess their own and others’ work through the lens of rigor and reproducibility is reinforced and measured at several stages of training.