Should Medical Schools require, encourage, or support active research by students?

As I was recently completing Medical Student Performance Reviews (aka “Dean’s Letters”) for our fourth year class I was, once again, struck by the scope and quality of research undertaken by our students. Our curriculum provides instruction in research methodology, statistical analysis and critical appraisal. It also features active participation in the generation of research hypotheses and development of methodologic approaches to test those hypotheses. However, our students are not required to complete a project to the point of publication during medical school. Nevertheless, many do just that. With the help of members of our Undergraduate Office staff, I compiled the following summary information:

  • 69% of the class were authors of a published article during their medical school career
  • those students contributed to a total of 242 publications
  • in 137 of those publications, our student was the first author

Lest you think these are simple topics of minor interest, let me provide a few examples of publications first authored by one of our students, chosen to highlight the variety and scope of work undertaken. (For the entire list of first author publications go here).

Chang J, Munir S, Salahudeen S, Baranchuk A, Morris C, O’Reilly M, Pal R.  Atrial thrombi detection prior to pulmonary vein isolation: Cardiac computer tomography versus transesophageal echocardiography.  J American College of Cardiology (2013)

Cho CK, Drabovich AP, Batruck I, Diamandis EP.  Verification of a biomarker discovery approach for detection of Down syndrome in amniotic fluid via a multiplex selected reaction monitoring assay.  Journal of Proteomics (2011)

Cusimano M, Pudwell J, Roddy M, Cho CK, Smith GN.  The maternal health clinic: An initiative for cardiovascular risk identification in women with pregnancy-related complication.  American Journal of Obstetrics and Gynecology (2013)

Dossa F, Gao FQ, Scott CJM, Black SE.  Relationship between white matter hyperintensities and hippocampal atrophy in Alzheimer’s Disease.  Canadian Journal of Geriatrics (2009)

Eid L Helm K, Doucette S, McCloskey S, Duffy A, Grof P.  Bipolar disorder and socioeconomic status: What is the nature of this relationship?  International Journal of Bipolar Disorders (2013)

Fernando SM, Szulewski A, Baylis JB, Howes DW.  Motion artifact reduction of ECG signal allows for greater chest compression fraction during CPR.  Canadian Journal of Emergency Medicine (2013).

Ferrara S, Bradi A, Pokrupa R.  Decreasing neurologic consequences in patients with spinal infection: the testing of a novel diagnostic guideline.  Canadian Journal of Surgery (2012)

Fitzpatrick AM, Gao LL, Smith BL, Cetrulo CL, Cowell AS, Winograd JM, Yaaremchuk MJ, Austen WG, Liao EC.  Cost and outcome analysis of breast reconstruction.  Annals of Plastic Surgery (2013)

Gray AB et al.  The effect of a coronoid prosthesis on restoring stability to the coronoid-deficient elbow: A biomechanical study.  The Journal of Hand Surgery (2013)

Joundi RA et al.  Persistent suppression of subthalamic beta-band activity during rhythmic finger tapping in Parkinson Disease.  Clinical Neurophysiology (2013)

Kokorovic A, Cheung GW, Breen DM, Chari M, Lam CK, Lam TK.  Duodenal mucosal protein kinase regulates glucose production in rats.  Gastroenterology (2011)

Koppikar S, Baranchuk A, Guzman JC, Morillo C.  Stroke and ventricular arrhythmias>  International Journal of Cardiology (2013)

Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG.  Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation.  Applied Physiology, Nutrition and Metabolism (2011)

Lun G, Atenafu EG, Knox JJ, Sridhar SS, Tannock IF, Joshua AM.  Use of a clinical assistant to screen patients with genitourinary cancer to encourage entry into clinical trials and use of supportive medication: A pilot project at a Canadian cancer centre.  Clinical Genitourinary Cancer (2013)

Osumek JE, Revesz A, Morton JS, Davidge ST, Hardy DB.  Enhanced trimethylation of histone H3 mediates impaired expression of hepatic glucose-6-phosphatase expression in offspring from rat dams exposed to hypoxia during pregnancy.  Reproductive Sciences (2013)

Rogers E, Wang BX, Zhu C, Rowley DR, Ressler SJ, Vyakarnam A, Fish EN.  A host factor that influences the neutrophil response to murine hepatitis virus infection.  Anitviral Research (2012)

Tohidi M, Robinson L, Graham T, Smith G.  Effect of caffeine ingestion on fetal heart rate activity.  J Obstetrics and Gynecology (2013)

Wang M, Reid D.  Virtual reality in pediatric neurorehabilitation: Attention deficit hyperactivity disorder, autism and cerebral palsy.  Neuroepidemiology (2010)

So all this begs two key questions:

How does this happen?

Should it happen? Put another way: Should active participation in research be encouraged or intentionally embedded into medical school curricula?

Let’s start with the easier, first question. Research participation of this breadth and quality comes about, in my view, as a result of three key and mutually interdependent factors.

blog-clarke1. Faculty leadership. We have been fortunate at Queen’s to have the strong support of our current and previous Deans (Richard Reznick and David Walker respectively) to the fostering of research at our centre. Undergraduate education has benefitted from this commitment in many ways, both directly and indirectly. blog-murrayImportantly, our student research efforts have been guided by the dedication and tenacity of two key undergraduate program leaders. Albert Clarke, now Emeritus Professor of Biochemistry, guided a Critical Enquiry course which was, for many years, a distinctive feature of our curriculum and engaged every student at Queen’s in an active research project. More recently, Heather Murray, Associate Professor in the Department of Emergency Medicine, has taken on leadership of the Scholar Competency in our revised curricular structure. In doing so, she has incorporated the spirit of Albert’s Critical Enquiry and embedded it into our curriculum such that every student participates in a discipline specific research group with the goal of developing a hypothesis generating proposal and appropriate research methodology.

2. Faculty support. These efforts, of course, could not have taken place without the active participation of many faculty whose commitment to medical education and research drives them to contribute their time and creative energy. In fact, no fewer than 60 of our full time clinical and basic science faculty members are involved in the support and mentoring of our students in the Critical Enquiry program. The effort they provide, I can assure you, is far beyond the compensation or recognition they receive. They do this, quite simply, because they “buy in” to the value of research in general, and its development in medical school in particular.

blog-students-13. Student engagement. As mentioned earlier, our students are not required to complete or publish their research proposals. At our annual Research Showcase, most of our student body and many faculty turn out to review and celebrate the student research accomplishments of the previous year. A casual stroll through the many posters, conversation with the authors and review of the works selected for oral presentation are sufficient to convince that the dedication of our students to the themes they have engaged is original, genuine and highly insightful. It also speaks to many of the qualities that we should be seeking in medical school applicants and fostering in medical school. All this would suggest we must be doing something right in both domains, and should certainly encourage our ever-evolving admissions processes and curricular

The second question I’ve posed is perhaps more complex and controversial. There is increasing competition for time within MD programs as curricular objectives and accreditation requirements become more expansive. Curriculum Committees are called upon to make judgments between equally meritorious proposals for “real estate” and for the attention of students. In doing so, they must address a variety of forces and influences from disparate sources. The relevant accreditation standard from the joint Canadian/American agencies reads as follows:

IS-14. An institution that offers a medical education program should make available sufficient opportunities for medical students to participate in research and other scholarly activities of its faculty and encourage and support medical student participation.

Medical schools would seem to be required to provide opportunities but not ensure all students participate actively. The implied meaning would seem to be that research participation is desirable but not mandatory component of physician training.

The Future of Medical Education in Canada initiative, now in implementation phase, has two key recommendations that would seem to speak to this issue, but perhaps with somewhat divergent messages.

Recommendation III: Build on the Scientific Basis of Medicine

Given that medicine is rooted in fundamental scientific principles, both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience. In addition, as scientific inquiry provides the basis for advancing health care, research interests and skills must be developed to foster a new generation of health researchers.

The final sentence of this recommendation would certainly seem to support an active research agenda. On the other hand another FMEC recommendation would seem to suggest medical education should take on a broader, less discipline-focused approach…

Recommendation VII: Value Generalism

Recognizing that generalism is foundational for all physicians, MD education must focus on broadly based generalist content, including comprehensive family medicine. Moreover, family physicians and other generalists must be integral participants in all stages of MD education.

While the call for medical schools to emphasize generalism is certainly not intrinsically inconsistent with a strong research interest, and recognizing that many family medicine specialists make valuable research contributions, it is equally true that the highly focused and largely university-centred approach of those interested in research careers seldom overlaps with the generalist approach. These two recommendations therefore provide a considerable challenge to medical schools and those developing admission criteria and designing curricula.

Another obstacle to the establishment of individual research within a medical school relates simply to the demands on faculty. Effective research requires one-on-one mentoring and supervision. That faculty-student interaction, to be effective, must be intensive and continuing.

So given all these challenges, why bother? There are probably many reasons we could cite, but I’ll provide my top three:

  • The ability to critically assess new information is an essential physician skill, and will be even more important in future years as the volume and pace of new information increases. There is perhaps no better way to acquire that skill than to have engaged personally in the process of hypothesis generation, study design, data collection, analysis, presentation, and finally defending that work through the peer review process.
  • The research process requires mastery of many of the physician competencies we value and aspire to develop in our students, specifically medical expertise, communication, management, scholarship and collaboration.
  • The possibility of sparking, in even a few of our students, an interest in a particular topic or simply an awareness of the power of research process itself is enticing and potentially far reaching. It’s hard to imagine that the minds that developed or contributed to the works listed above won’t be positively influenced and perhaps inspired as a result of the experience.

Unfortunately, we can’t look into any crystal ball to know how many of the young researchers in our graduating class will carry that interest into their careers, or what influence their work will have. However, I think we can take some satisfaction that we have collectively done our best to provide opportunities that will enrich and inform those careers.

Many thanks to Katie Jones, Amanda Consack, Jane Gordon and Jacqueline Schutt of the Undergraduate Office for their assistance in the compilation of information for this article.