Navigating the Path: Making Smart Choices… Advice to Physician Scientists on Choosing a Clinical Specialty

Reviewer #1 (Public review):

Summary:

This brief piece by Swartz and colleagues outlines the complexities surrounding the choice of clinical specialty for physician-scientists. It is, in general, clear and well-written, and it will be useful to research-oriented medical students choosing a path and to the mentors who are guiding them.

Strengths:

The writing is clear. The points made are not profound, but they are important and will be of use to the intended audience.

Weaknesses:

I have only minor suggestions for improvement. There are some areas of redundancy where the article could be tightened up by consolidating.

Reviewer #2 (Public review):

Summary:

This article is a useful compendium of advice for MD/PhD students (and research-focused MD students) to consider when it is time to decide on a clinical field for residency training. The authors are a distinguished group of physician-scientists and program directors who are drawing on published data and their own experience as mentors to provide advice and resources to students about to make what can be a career-defining choice. It makes an effective argument for considering important differences between clinical fields in their ability to sustain research integration, provide mentorship, meet lifestyle expectations, and foster a long-term career as a research-focused physician-scientist.

Strengths:

(1) A lot has been written about physician-scientists as an endangered species. Given the important role that physician-scientists can play if they engage in research that is informed by experience in patient care, not nearly enough has been written about the choices that students make during training that can keep them on track or throw them off.

(2) The article provides not only general advice, but specific information in the 2 tables that can help trainees to weigh their priorities and consider their options.

(3) Among the best advice is to weigh clinical demands, maintenance of procedural skills, recognition of the impact of research time on salary, and the impact of high salaries on the tension between research effort and clinical effort in clinical departments, which is where most physician-scientists in academia are employed.

Areas for potential improvement:

(1) Some of the most useful pieces of advice are scattered through the text when they might be more impactful if focused. For example, what are the 4 or 5 most essential factors that someone in an MD/PhD or an MD program should weigh when they are deciding between clinical disciplines? There are also published data on the experience of past graduates in achieving a research-focused career in each clinical discipline. How should that data be applied by trainees? What are the factors that should be weighed in deciding where to work as a research-focused physician once training has been completed?

(2) Some clinical fields at academic institutions have proved to be much more hospitable to careers as research-focused physicians than others. Published data highlight the challenges. I believe the authors have tried very hard to present a balanced perspective, but in the process, they have, I believe, missed an opportunity to guide trainees and make them aware of what they should look for to avoid making a decision that may prove incompatible with their long-term goals.

(3) An issue that hasn't been raised: Where will be the jobs for physician-scientists who have an MD {plus minus} PhD and want to do research and discovery? How many openings will there be for physician-scientists in academia 5-10 years from now? In industry? How are recent events in Washington affecting the continuation of those jobs? Unfortunately, I am not aware of labor statistics for physician-scientists, but perhaps the authors can find them.

(4) Additional questions that can be raised and addressed in the article: Should one of the "smart choices" in the article's title be where you do the residency, and not just which residency you do? How important is it to be at a successful, research-intensive medical center/university, both during and after residency and fellowship training? If being in an institution where there are numerous very successful physician-scientists and scientists improves the likelihood of being able to sustain a physician-scientist career, how should graduating students improve their chances of being at one of those institutions?

(5) In every clinical discipline, there are departments that value physician-scientists more than other departments and invest accordingly. What advice would the authors give to help graduating students identify those departments?

Author response:

Thank you for the valuable feedback. We will be updating the manuscript to incorporate the reviewers' terrific suggestions. We specifically have:

• Reduced redundancy and streamlined overlapping sections (especially around research alignment, protected time, and clinical demands)

• Made the core decision-making framework more explicit and easier to extract (in a new Table 1, with clearer synthesis in the text)

• Strengthened the emphasis on institutional/program context as a key determinant of success—arguably as important as specialty choice

• Added more actionable guidance for trainees on how to evaluate departments (e.g., NIH Reporter, T32 presence, R01 density, K→R track record)

• Included a slightly more explicit statement acknowledging that while all specialties can support physician-scientist careers, the structural ease varies and may require different levels of negotiation/support

We did not address the broader workforce/job market question, since it feels outside the scope.