Horace Rhee '95 graduated from Northwestern with a B.S. in biomedical engineering in 1999, then went on to get his MD-PhD at the University of Chicago Pritzker School of Medicine (for the MD) and The Rockefeller University (for the PhD). He next completed his residency and fellowship at Stanford Hospital and Clinics, and is currently an instructor there. Xinyi Zhou '10 and Dr. Rhee chat about how you become a doctor and where he is in that process.
We were in the old Blair building; I've never experienced the new Blair building. I've just only heard about it. It was a nice community. You're on the bus with them in the mornings, on the bus going back home. You take a majority of the classes with similar Magnet people. It offered a great curriculum to prepare me for college. In some senses, college was easier than high school. I don't know if it was just that you were just better able to be organized, to carve out your time and be efficient with your time… I mean the course load is obviously harder [in college], but just the foundation that the Magnet set forth in terms of what you learned, and the structure, allowed people to be really prepared for college.
How did you decide to major in biomedical engineering (BME) at Northwestern?
Just an interest in biology and technology. I thought it would be nice fit. I did well in the engineering classes but then decided to continue my interest in medicine.
So did you go into it planning to then go to med school?
I was definitely premed from the beginning. But BME just seemed more like a natural transition from being in a Magnet program. I think BME back then was still relatively new, it was 10 years old, 15 years old maybe. It was hard sciences applied to medicine and biology and I thought it would be cool.
Could you explain the process of becoming a full-fledged doctor?
My path's a little different [as a MD-PhD]. But if you want to become a physician, there's certain premed classes that most medical schools require that prepare you for the entrance exam. Most people take those during college, and then they apply for medical school. Med school is a four year process of learning both the preclinical, which is the book years, and the subsequent two years are the clinical years where you do clinical rotations on a bunch of different specialties. That helps you at that point, determine what field you want to get further practical training in. After four years of med school you apply for a residency, which can run anywhere from three to seven years depending on what field you go into. That's where I am.
Residency is sort of the initial clinical phase. Within certain fields such as internal medicine, pediatrics and general surgery, you can further specialize by doing another fellowship. Internal medicine includes the one I'm in, gastroenterology. But you can also practice after just going through general surgery. You would just be more of a generalist. Primary care tends to be physicians who have done the three years of medical residency, but didn't do additional years of specialty training.
So how was your path different as a MD-PhD?
It's basically designed for people who are interested in the clinical aspect of medicine, but want to have a more investigative career. The investigative part can be anything: more basic sciences, or more applied, or clinically oriented research. Even social sciences. Even though [the PhD] has traditionally been in some biological or physical science, there are some programs in which you can do a PhD in social science. I went to UChicago and there was one guy who did a PhD in economics because he was interested in healthcare economics. You could probably also just do psychology or sociology.
So a MD-PhD is for people who want to use medicine, but not just practice. For people who want to do investigative work associated with it. You're doing both at the same time -- it usually becomes a 7-9 year process. But you end up flipping back and forth -- you kind of put on one half for a while, and put another half on for a while. Typically what happens is people do the first two preclinical years, when you're just taking classes, exams, anatomy and so on, and then you take a break and do your PhD. Then you head back to your clinical years to give you an idea of what you do want to do in a residency.
Your current job title is instructor -- does that mean you teach classes?
[Instructors] are basically people who finished the PhD, but don't have an independent position. It's an academic transition -- I call it purgatory. I help out the med school when they have the GI block in the lab. One of my colleagues teachers the GI block and they have a lab course, so I just participate in the lab course for the med school.
But most of my teaching role is really just proctoring the fellows. Basically a year ago, I was one of them. Now I'm attending for them. It's basically being the attending physician. In an academic medical center, all the teams are structured in a way such that you have the attending position on top -- the physician on record for any hospitalization or patient encounter. Underneath them, especially in an academic center, you'll have a team of trainees, which is the first year resident (the intern), then a resident who has finished their intern year, and then you have a fellow. It's just medical hierarchy. But everyone works as a team, at least out here -- I'd say academic places on the east coast are a little more hierarchally rigid. They keep people in line. It's a little more collegial and relaxed on the west coast.
What would you like to do next?
So I'm a gastroenterologist [as a MD]. The PhD I got was in stem cell biology. I studied the development of hair follicles and the origins of hair follicles. [Rhee, Horace, Lisa Polak, and Elaine Fuchs. “Lhx2 Maintains Stem Cell Character in Hair Follicles.” Science 312.5782 (2006): 1946–1949.] With that background, I went into GI because it was another epithelial organ outside of skin. It was attractive clinically and I like it from a procedural aspect. So I study a disease called Barrett's esophagus, with is a condition that develops in some individuals with chronic reflux disease. The inside of the esophagus turns into a glandular intestinal-like epithelium. Normally it is lined by a squamous epithelium. [Barrett's esophagus] is the primary risk factor for esophageal cancer. Often people don't know that it exists or that they have it. The other issue is that there's a ton of people with reflux disease, but a very small amount of people develop Barrett's. So one of the difficulties is identifying the patients at risk, and in the patients that have Barrett's, to see who is at risk of developing esophageal cancer. We don't currently have tools to evaluate and follow patients long term.
I'm trying to understand how [Barrett's esophagus] arises both from a cellular and molecular form of view. That's what I've worked on as a fellow, and I'm continuing on here, trying to secure some money [to keep doing research]. But what happens a lot is, you may really like what you're doing, but in the end, somebody else has to like it for you to move forward. That's the only way something's going to get funded: somebody who controls money says yeah, that's a great idea, or I really believe in who you are. You can have all these ideas but you can't work on it. You need the resources to execute, to make something attractive for somebody on the outside, whether it’s the journal reviewers or the grant reviewers. To be honest with you, that's kind of where I am -- I definitely like what I'm doing, but at the same time you realize, what if other people don't like it? Then it's going to be hard to continue to pursue it. But having a clinical practice that's also relevant to the diseases that you're studying is the ideal of anyone in this field.
How do you know if a MD or MD-PhD is right for you?
I didn't really know much better when I went to college. I just came from this science engineering background and it seemed like BME would be a nice transition or blend into some sort of medical thing. But in terms of figuring out whether it's right for you, you have to ask yourself, do I still enjoy this? Is this really what I want to do? Do I get excited about it? Because it's a long, long road. People at my stage, they might have full-fledged careers. They're probably in executive positions at companies, or they've been fully practicing for five or six years. [For me] there's this opportunity delay, because you're continuing to train, whereas other people may already have moved on. They're probably making a whole lot more money. I think even when I started out the MD-PhD, it wasn't 100% being sure. It was, I like science or biology, I like medicine and I was going to try out both, and you do both and you realize there's good things and bad things about both, and it's kind of where I am still. Trying to merge the two together in some sort of way that's going to be attractive. But as long as you still enjoy what you're doing, it's probably the career for you.