In primary care, doctors may be able to work a combination of clinical hours and entrepreneurial work hours. This is what Nazem, who is finishing up his internal medicine residency and searching for entrepreneurial work in conjunction with a primary care fellowship, hopes to do. The only issue with these dream-job setups is that graduates often end up having to cobble them together themselves. “You really have to be enterprising and committed because you will run into wall after wall after wall,” said Nazem.

Merck CMIO and Harvard M.D./M.B.A. graduate Sachin Jain says that’s what you often have to do in the business world anyway. “This whole notion of a path is very medicine. It’s not very business,” says Jain. “In business, it’s very organic, you have to be able to see the opportunity and lead change towards that opportunity.” The timeline and application structure for residencies or fellowships are very rigid, while the hiring for startups, for example, is fluid.

Another challenge is that most clinical residencies don’t allot time or outlets for side projects during work hours. Marissa Wagner interrupted her residency to earn an M.B.A. at Stanford. When she returned to residency in 2013, she tried to continue a project she’d started at Stanford, but says it was a struggle to do so when working 80 hours a week. “If you decide to go back and finish residency, you sort of have to leave this stuff, at least to a certain degree,” she says.

There are an increasing number of residency programs seeking to solve this dilemma. Duke started the management and leadership pathway for residents in 2009 to solve the problems of “accidental administrators in medicine” and potential “atrophy” of business school skills during residency. Duke declared that there should not be a “binary choice between business or medicine.” The students have a minimum of 15 months of management experience over the course of the program, with approximately 6 months on clinical rotations and 6 months in management modules for two to three years.

Jain did a training program at Brigham and Women’s Hospital called HemiDoc, where he spent 50 percent of his time in residency and 50 percent pursuing his medical and business research and teaching. While in residency, Nazem has been working on a medical education side project to create and implement a residency-fellowship training pathway specifically for management and innovation in medicine. “Like there are sub-tracks in internal medicine, there should similarly be a track to train people who intend to be in clinical leadership roles and innovation roles,” he said.

Even in a typical residency, though, business training often comes in handy. When Chandler asked residency programs across the country for evaluations on UC Irvine graduates, she found that “in almost every category, M.D.-M.B.A.s were listed as higher: even in non-business areas.” She says she doesn’t know if there is self-selection bias for these kinds of dual degree programs, which would mean that students who choose to pursue dual degrees may be more competitive and well-rounded to begin with.