Abstract
Background Advances in biomedical research during the last decade have highlighted the necessity of attracting greater numbers of physicians to careers that include a research component. Physician participation in research is essential to increase the number of clinical and translational studies performed, as well as to educate the public about the importance of clinical trials and to assist in recruiting participants. We hypothesized that attractive research opportunities that included faculty mentoring, recognition of participation, and rewards for accomplishments would encourage medical student participation.
Methods The Medical Student Research Office was created at Mount Sinai School of Medicine in 1996 to develop structured research programs and advise students looking to undertake a research project. Data from students participating in the summer research program and Medical Student Research Day, from the research section of the Medical Student Performance Evaluation, were collected from 1996 to 2004.
Results For the last 4 years, the majority of medical students did research following the first year of school. Students did basic and clinical research, although most preferred clinically oriented or translational projects. Participation in Research Day and the number of publications suggest that interest is growing, including that by traditionally underrepresented groups.
Conclusion Although it is too early to assess the long-term effects, the research programs offered led to greater numbers of students who did research, including those in traditionally underrepresented groups. Moreover, students were highly satisfied with their experiences, with 80% feeling that it increased their interest in applying principles they learned to the practice of medicine.
The decline in the numbers of new clinician-scientists threatens to limit improvements in health care delivery.1-3The design of programs to prevent disease onset and the translation of laboratory discoveries to clinical trials aimed at identifying new diagnostics and therapies will require teams composed of basic scientists, clinicians, biostatisticians, and clinician-scientists, each with a unique role. The reasons that young doctors are rejecting research careers are complex4and may include high educational debt, coupled with the reduced compensation of researchers compared with physicians in clinical subspecialties; the fear among students, as recently documented for women, that it will be too difficult to balance research and medicine and still have a satisfying family life5; the uncertainty of the grant support process; and only a vague understanding of how research fits in with a career in medicine.
Medical schools bear some responsibility for this dilemma. Although the practice of evidence-based medicine, with its critical appraisal of the clinical literature, is important to be certain that patients receive optimum medical care, the lack of a firsthand research experience for many students may reduce their comfort and familiarity with the scientific literature. A recent study investigating the quality of health care in the United States reported that patients received only 54.9% of recommended care when 30 acute and chronic conditions and preventive care were considered together.6It is reasonable to predict that scientific literacy would be greater for those who have had research experience and that this would help produce lifelong learners familiar with searching the scientific literature to obtain the information needed to deliver the highest-quality clinical care and improve the above numbers. Research experience would also provide medical students with an appreciation of the role that research plays in developing new standards of care, something that would be expected to produce clinicians who better understand the complexity of clinical trials and contribute to their eventual success by helping recruit patients. Finally, as suggested by Nathan and Varmus, most medical educators believe that positive research experiences influence a student's eventual career choice and thereby might open new doors for students.7
The Medical Student Research Office was created at Mount Sinai School of Medicine in 1996.8The goals of the program were
To provide a positive, rewarding, and relevant research experience during medical school
To increase student comfort with the scientific literature
To increase understanding of the importance to research in managing patients
To maintain or increase student interest in research
To increase women and minority participation in research during medical school, groups traditionally underrepresented in research
As a result of strong student interest, structured research programs were developed. We hypothesized that increased numbers of students would engage in research if they were offered help in identifying an interested and available mentor, presented with opportunities that were sufficiently interesting to compete with the other available activities, placed in projects that could yield results in the short time frame that students have available, provided with financial support, and rewarded for their accomplishments.
Although it is too early to have any long-term outcome data concerning whether these programs impact on participants' future career paths, our results suggest that there was a high degree of student satisfaction with their research experience and that the overwhelming majority felt that it increased their interest in applying research to their practice of medicine. Thus, such programs may represent one approach to generating larger numbers of clinician-scientists.
METHOD
Study Population
Students from all 4 years of medical school can choose to participate in research programs and thus were eligible for this study. Data for students pursuing an MD degree only and not those enrolled in an MD/PhD program were included because we are focusing on this traditional MD group, for which fewer mechanisms for research support and training are available.
Data Collection
To ensure accuracy, data were incuded only if they were from research programs developed and administered by the Medical Student Research Office. These included a summer research program (2001-2004) and the Medical Student Research Day (1996-2004). In all cases, students submitted either an abstract or a research proposal, along with a faculty letter of support to document participation. Data on publications (1998-2004) were obtained from information submitted by students for the research section of the Medical Student Performance Evaluation. Publications were verified by the Medical Student Research Office and checked for accuracy on the basis of hard copies of the publications that the students provided or, if the mansucript was in press, letters from the journals confirming acceptance. This study was reviewed by the Mount Sinai Grants and Contracts Office and determined to be exempt from Institutional Review Board review. To evaluate student satisfaction, students who participated in the summer research program were asked to complete an anonymous, Web-based survey of their experience. Using a 5-point Likert scale, questions were structured with a statement that requires selection of a response related to their overall agreement with the statement, with 1 indicating strongly disagree, 3 being undecided, and 5 indicating strongly agree. A choice of “unable to evaluate” received a score of 0. The only exception was the question that asked students to rate the overall experience. Although the responses were also on a 1 to 5 scale, in this case, 1 was poor and 5 was outstanding.
RESULTS
Structure of the Medical Student Research Program
Students are recruited to the research program beginning the first day of school at orientation, when they are informed about the chances for them to do research throughout the 4 years of medical school. These include electives during all 4 years, summer research after the first year, and a scholarly leave, usually following the second or third year, during which they spend a full year doing research. Scholarly leaves can either be part of a structured program (eg, Doris Duke Clinical Research Training Fellowship, Howard Hughes Medical Institute Research Scholars Program or Research Training Fellowship) or arranged independently by a student who identifies a mentor on his or her own. Subsequently, students are informed about research opportunities at class meetings and by electronic mail. Finally, the associate dean for medical student research meets with interested students individually to answer questions and help them choose a mentor. The research program is inclusive, and we encourage the participation of students regardless of whether they have done research before.
Majority of Students Obtain Research Experience Early in Medical School
Summer research following the first year of medical school is the first time students can do full-time research. Almost all students devote 8 weeks to their projects, although students are supported if they spend a mininum of 6 weeks. Opportunties exist in basic, clinical, translational, epidemiologic, behavioral, health outcomes, education, or community-based research. In 2004, 18 different departments were represented, with community and preventive medicine, medicine, orthopedics, and psychiatry welcoming the greatest number of students. Students are advised to begin to look for mentors early in the second semester to be able to submit an application for summer funding by the April 1 deadline. Students choose their mentors based on advice from the associate dean for medical student research, other faculty members, or more experienced students. They also rely on on-line resources created by the Medical Student Research Office, the Graduate School for Biomedical Sciences, and individual departments that include faculty biographies. Because our goal is to give students a chance to experience research, all students with mentors who develop projects that the members of the Summer Research Advisory Committee find doable within the time frame are accepted, although some projects require further refinement. To show our support for students interested in doing research and to ensure that everyone who wanted to do a research project could afford to, since 2001 we have provided stipends to all students who submitted an abstract approved by the Summer Research Advisory Committee. Funding comes from a variety of sources, including the federal work/study program, the Mount Sinai Alumni Association, and a grant from a member of the board of trustees.
A 250-word abstract describing the project, written primarily by the student but with input from the mentor, is required. In many cases, students use elective time in the spring to develop their projects, do background reading, and prepare their abstracts so that they are ready to begin in earnest once school ends. Participation in the summer research program is strong, ranging between 54 and 65% of the first-year class from 2001 to 2004. In fact, this is somewhat of an underestimate of the total number because some students arrange to do research at other institutions on their own. Because students sometimes arrange these experiences on their own and the summer is not part of the school year, we are not able to track them reliably. Information about participation before 2001 is not available because it was only since funding was provided that we have had access to this information.
Research Day Gives Students the Chance to Present the Results of Their Studies
Medical Student Research Day is a chance for students to show the rest of the Mount Sinai community what they have done, as well as to help ensure that they analyze their results. They receive training in how to write an abstract and how to prepare a poster or give an oral talk. More advanced students may use the opportunity to hone their presentation skills for presentation at a national meeting. Research Day abstracts are due at the end of the summer so that students can prepare them while still under the supervision of their mentor rather than months after completing the work when they are back in class. Research Day is open to all students, regardless of whether they did their research at Mount Sinai or another site. Four students are selected by faculty on the Research Day Advisory Committee to give oral presentations each year based on their submitted abstracts. One presentation must be by a student who did basic research, one by a student who did clinical research, and one by a Medical Scientist Training Program (MSTP) student. Basic and clinical projects were self-declared but verified by a faculty member. The fourth presentation can be in any category. All abstracts are published in the Research Day Abstract Book. Only four students give oral talks so that this remains something special, because of time limitations, and, most importantly, to put the emphasis on poster presentations because they foster interaction and active participation by students and faculty. They are scheduled for a 2-hour session in the early afternoon, and a buffet lunch is provided. Students are asked to be at their posters for only 1 of the 2 hours so that they also have the chance to view other posters. We position the posters in an area with access to the main lobby so that they are visible.
Participation in Research Day has been strong since the first year it was held, 1996, with the exception of 1997 (Figure 1). This may be explained by the fact that in this year the Medical Student Research Office lacked a director. From 1998 to 2004, interest continued to grow. Of particular interest is that the percentage of women who presented their work rose from 20% in 1996 to 54% in 2004 (Figure 2). Most of the growth in Research Day participation could be attributed to the increased presence of women students, something that was not accounted for by an increase in the representation of women in the class (results not shown). Participation by underrepresented minorities (URM) also rose, from 5% in 1996 to 11% in 2004. This jump, as with the increase in participation by women, could not be accounted for by an increased representation of underrepresented minorities in the class (results not shown). Students carried out both basic science and clinical projects, although in all years but one, February 2002, somewhat more favored clinical projects, and this trend may be getting stronger (Figure 3). This is consistent with data showing that MD students tend to choose mentors from clinical departments even if they are doing basic science research (data not shown). The program is supported by the dean for medical education, students' mentors who generally cover costs associated with student posters, and the Mount Sinai Alumni Association, which sponsors the buffet lunch.
Scholarly Leaves Give Students Increased Time to Pursue Research
Programs exist to enable medical students who are not pursuing a PhD to incorporate research into their medical education. One example is the “year out” programs that have been developed, during which students do a year of full-time research. The Doris Duke Charitable Foundation, the Howard Hughes Medical Institute, the National Institutes of Health (NIH) Clinical Research Training Program (CRTP), and the Sarnoff Foundation offer excellent 1- or 2-year programs in basic or clinical research to medical students. The Doris Duke Clinical Research Fellowship Program and CRTP, both of which focus on clinical research, specifically require a didactic component as part of the year to expose students to experimental design, biostatistics, ethics, and clinical research design. Early exposure to research as a student may influence the choices they make about their future training after medical school.
Whereas the number of students at the Mount Sinai School of Medicine who choose to do a year of research has been rather constant between the 2000-2001 and 2004-2005 academic years, with a mean of 8.6 ± 2.4, the number of participants for 2005-2006 has increased to 24. Interestingly, 19 of the students are interested in doing a year of clinical or translational research.
Since 2002, Mount Sinai has been 1 of 10 sites of the new Doris Duke Clinical Research Fellowship Program, which is directed at training students how to do clinical research and has proven very popular with our students. The program is specifically focused on clinical research training and has a didactic component as well. Participants take classes that are part of the K30, master of clinical research, or master of public health program. The program provides stipends, as well as travel money, and support for other research-related activities for four students. Mount Sinai funds four additional students with resources from the Department of Medical Education, the Department of Medicine, and the General Clinical Research Center. Applications have increased dramatically since the first year, from 2 in 2002-2003 to 11 for 2005-2006. The Doris Duke fellows live in the medical student residence, and this has helped enormously to publicize the full-year research experience and to offer students increased opportunities to learn how to conduct clinical research studies. The program has been highly rated by participants on the anonymous exit survey distributed by the foundation, and it is tempting to speculate that the increased interest in full-time research may be a reflection of these student ambassadors.
Research Achievements Are Rewarded
A variety of external and internal rewards and prizes not only recognize outstanding achievements but also show that research in general is valued. Students who publish first author manuscripts on original research in peer-reviewed journals or submit their results in the form of a manuscript that is accepted by an ad hoc faculty committee graduate with distinction in research. This is noted on their diplomas, and they are honored at the graduation awards and prizes ceremony. In addition, summaries of research projects, along with citations of publications and abstracts, are included in the Medical Student Performance Evaluation and contribute to the student's final rank-in-class descriptor. Students are eligible for travel grants if they are going to present the results of their research at external meetings. This is considered an excused absence from classes or clerkships, although any work missed must be made up. Several additional research prizes are awarded at graduation.
Publications by Graduating Students Are on the Rise
Planning a research study, analyzing data critically, and preparing work for publication are important skills for students to learn. Publishing their work shows them how new knowledge is disseminated, teaches them an important skill, and gives them a tangible product. The increased student commitment to research has resulted in greater productivity, with the percentage of graduating students publishing peer-reviewed manuscripts more than doubling, from 11% in 1998 to 25% in 2004 (Figure 4). The percentage of students as first authors also increased from 5 to 13% within the same period, and the absolute number of manuscripts published by the graduating class increased from 22 to 52 (results not shown). Based on the American Association of Medical Colleges Graduating Survey, the percentage of Mount Sinai students who are authors or coauthors of a manuscript submitted for publication was above the mean for all medical schools from 1998 to 2003 (results not shown).
Students Are Very Satisfied with Their Research Experiences
Continued growth of the program depends on students believing that they have benefited from their research experiences. We used the summer student research experience at Mount Sinai to measure student satisfaction with the research opportunities available to them. Feelings about the summer program are especially important because for most it is their first research experience. For the 2004 and 2005 summer research programs, all students who did summer research at Mount Sinai and who received funding from the Medical Student Research Office were asked to complete an anonymous but mandatory Web-based survey of their experience. For the summer of 2004 (class of 2007), 54 of 55 students completed the survey. For the summer of 2005 (class of 2008), 57 of 57 students completed the survey. Between 0 and 4 students were unable to evaluate an individual question.
The results demonstrated that, overall, students felt that their projects were challenging. About 90% felt that they had learned a lot and were glad they did the project. Approximately 80% felt that their experience increased their interest in applying research to the field of medicine. Approximately 70% stated that it increased their interest in research, and 20% were neutral. Approximately 75% rated the overall experience as excellent to outstanding, and 10 to 15% rated it as very good. There were no statistically significant differences in the responses for the students doing summer research in 2004 and 2005.
DISCUSSION
Articles reporting a crisis in research by young physicians abound, with some groups reporting that women were less interested in a research component to their careers than men.5,9Given recent reports suggesting that physicians who carried out research in medical school are more successful in obtaining funding than those who had not,10,11more frequently do research during their postgraduate years,12and obtain faculty positions that had a research component,11it is important to stimulate student interest in research. To achieve this, many medical schools have created an infrastructure to assist medical students interested in undertaking research projects. A formal search of several scientific and educational databases revealed that little has been published on the structure of these programs. However, examination of the research programs on the Web sites of medical schools ranking among the top 20 on the US News and World Report index revealed that the majority had well-organized descriptions of available mentors, external and internal sources of support, research honors programs, and opportunities for students to present their work. Two reports describe mentored, curricular programs created to enable students to undertake a required scholarly project during medical school.13,14Several programs have reported data regarding student satisfaction with their research experiences.15-18Although the specific questions posed to the students varied, those surveyed in these studies were uniformly positive about their research experiences. Two programs reported that doing research as a medical student was associated with continued involvement in research following graduation.12,19
At Mount Sinai School of Medicine, medical student participation in research begins during the first year and continues throughout school. Although students do both basic and clinical research, most of our students prefer clinically oriented or translational projects (see Figure 3). Several end points, including participation in Research Day (see Figure 1) and the number of publications (see Figure 4), suggest that interest is growing. The findings may reflect, at least in part, the infrastructure created to help students identify mentors, obtain financial support, and reward their accomplishments. It may also be a result of student satisfaction with their research experiences or the fact that if the research mentor is a physician, a research experience may allow students to get an idea of a career that combines research and clinical medicine. Of particular interest is the marked increase in female medical students who participated in Research Day (see Figure 2). It will be important to determine whether these changes influence career choices after graduation. We are beginning to track these questions.
Historically, medical students who are not enrolled in MD/PhD programs faced particular difficulties in obtaining research training. As pointed out by Schrier, they were forced to identify mentors and to carve out time, during or after medical school, on their own.20The curriculum most medical students followed enabled only the most motivated or those fortunate enough to meet a nurturing mentor to have experience in conducting original research. Didactic training was virtually nonexistent. Such policies meant that many bright and talented potential researchers were missed. The program described in this report is composed of several components so that schools can take one or more portions and integrate them into what is already in place.
In an attempt to encourage student participation in other ways, the federal government established loan repayment programs for young physicians who engage in clinical research and the number of programs to support a full year of research have increased.21The increased interest we have seen in such programs, particularly the Doris Duke Clinical Research Training Fellowship, suggests that either the presence of students participating in the program or the availability of funding for a full year of research at their home institution has motivated students to get involved in research.
Long-term follow-up is required to track the ultimate careers of our students and their continued involvement in research, their publication record, grant submissions, and the education of patients about the benefits of clinical trials they may lead. Measuring these outcomes is important but difficult because they may not occur for 5 to 10 years and are impacted by various other factors during medical school and residency. Evaluation of short-term outcomes suggests that programs to train students how to design and carry out research studies that are integrated into existing strong institutional research programs and the medical education infrastructure are attractive to students. The results indicate that approximately 90% felt that they learned a lot and were glad they did their projects, 70% said that it increased their interest in research, and 75% rated the overall experiences as outstanding to excellent. Thus, such initiatives may contribute to the goal of the NIH Roadmap of creating clinical researcher scholars.
ACKNOWLEDGMENT
We are grateful to Merril Schindler for excellent help with the preparation of figures. We also thank the Mount Sinai Alumni Association for their support of medical student research programs and Grace Oluoch for excellent administrative support.