Dr. Ana Marušić is professor of anatomy and Dr. Matko Marušić is professor of physiology and immunology, both at the Zagreb University School of Medicine, Zagreb, Croatia.
Correspondence and requests for reprints should be addressed to Dr. Ana Marušić, Zagreb University School of Medicine, šalata 3b, 10000 Zagreb, Croatia; e-mail: 〈firstname.lastname@example.org〉.
The authors acknowledge the critical efforts of their colleagues from the Zagreb University School of Medicine in creating and running the course described here: Dr. Jelka Petrak, Dr. Mladen Petrovečki, Dr. Danka Grčević, Dr. Ivan Krešimir Lukić, Dr. Nataša Kovačić, Dr. Aleksandra Mišak, Dr. Vedran Katavić, Dr. Kristina Fišter, Mr. Darko Hren, and Mr. Marko Kljaković-Gašpić.
In this article, we describe the goals, development, and introduction of a course on scientific methodology and communication into the curriculum of the largest medical school in Croatia, a country outside of the mainstream scientific world.
Croatia belongs to the so-called scientific periphery, characterized by the smallness of its scientific community, lack of finances and critical mass of productive researchers, and language/communication barriers.1 Although the promotion of academic physicians is primarily based on scientific publications, the scientific productivity visible in publications devoted to mainstream science is low; i.e., scientific work is rarely published in journals indexed in widely used bibliographic databases, such as Medline or Science Citation Index. A study of scientific publications from Croatian universities in the 1986–1995 period showed that the total number of publications from all four Croatian universities was much smaller than that of a single comparable university in Europe (Ulm, Germany).2 Moreover, most of the research performed during graduate education for the MS and/or PhD degree (obligatory for medical academics) does not get published in the mainstream journals: less than 15% of MS theses and less than 35% of PhD theses result in articles published in journals indexed in Medline.3
In our work as researchers and teachers at Croatia's largest and oldest medical school, the Zagreb University School of Medicine,4 and later on as editors of a general medical journal published in English, we saw that the poor scientific productivity in Croatia was a direct result of both long-neglected education in research methodology and lack of incentives to publish in the mainstream journals.1 Low productivity of Croatian researchers, low criteria for academic advancement, and low quality of publications in a great number of local journals formed a vicious circle of inadequacy for the Croatian academic and scientific community and its scientific journals.1 One of the reasons why we started a scientific journal in 1992, despite the fact that 37 journals already existed in the biomedical field in Croatia at the time,5 was to show our colleagues that they conduct research that is important to the whole scientific community and that they should not be afraid of presenting their findings to the world. Our work on the first issue of the Croatian Medical Journal coincided with the 1991–1995 war in Croatia, prompting us to document its medical aspects. Once again we saw that Croatian physicians had valuable data but most often lacked skills to present those data in a scientific article.6 Being primarily medical teachers, it was logical for us to educate our authors: we introduced an “author-helpful” policy of prereview to teach authors the basics of presentation skills.7 Provided that the data were sound and the topic interesting and important, we worked with authors on their articles to make them appropriate for an international peer-review process. The most difficult problem was not English but lack of understanding of basic principles of data presentation and scientific writing. In this way, we helped many Croatian physicians to produce important reports, both for our journal and other international journals.8
Course on Principles of Scientific Research and Communication
Although we enjoyed working with authors, we also realized that a greater effort was needed to improve the skills of academic physicians in research methodology and writing. In the true spirit of preventive medicine and its long tradition at the Zagreb School of Medicine,10 our journal focused its educational efforts on future authors: medical students. With the support of the school administration, four members of the Editorial Board introduced a mandatory graduate course, Principles of Scientific Research in Medicine, into the medical curriculum of the Zagreb Medical School in the 1995–96 academic year; the course is now an accepted part of that curriculum. We could not draw from the experiences of others because principles of scientific research and communication are rarely taught at medical schools in a comprehensive way,11 although there is a growing awareness internationally of the need to teach communication, especially writing skills, early in a scientific or academic career.12 Based on positive experience from other settings,13 we integrated many aspects of teaching evidence-based medicine (EBM) into a preclinical course aimed at second-year medical students. Although some colleagues suggested that the best time for the course would be the last two years of medical studies, we believed that students could acquire critical appraisal and communication skills during the preclinical years. This would allow them to master some introductory EBM principles and enter clinical rounds with some knowledge of how to critically appraise clinical information.
In creating the course, we aimed to develop students’ knowledge and skills in scientific research and critical appraisal of information, as well as foster the attitude toward science and scientific methodology. By the end of the course, the medical student should be able to comprehend (1) research terminology in medicine; (2) the importance of setting and testing a hypothesis; (3) principles of study design in clinical research; (4) the importance of a statistical way of thinking in medicine; (5) principles of finding information in medicine; (6) the structure of a scientific article and other forms of scientific communication; and (7) basic principles of responsible conduct of research in medicine. The student is expected to develop basic observational and organizational skills to find a desired scientific article, recognize the study design described in the article, critically appraise the study, and write a structured summary of a published paper. In this way, he or she can appreciate the importance of critical appraisal in clinical work, EBM, clarity of scientific information, and the need for continuing independent learning of critical appraisal skills.
The course has three components: lectures, discussions in medium-sized groups, and problem solving in small groups. It focuses on five themes: (1) principles of scientific research; (2) access to literature and bibliographic databases; (3) practical approaches to the collection and presentation of data; (4) principles of assessing and writing a scientific article; and (5) responsible conduct of research (see Table 1). Each of the five themes is covered in a one-hour or two-hour core lecture, followed by three seminar discussions in groups of 20 students. There are set topics for the discussion, chosen from a textbook by the four teachers/editors, but the forum is generally unstructured and open to the discussion of relevant issues. The final component of the course comprises small groups, in which eight to ten students work on a problem related to finding and retrieving medical information, planning experiments and organizing data, assessing and writing a scientific article, and case studies in responsible conduct of research. Data examples and journal articles used during these exercises always relate to clinical research, which students, still doing basic science courses, are able to understand. The topic of responsible conduct of research is a new addition to the course, since 2003. As journal editors, we were aware of the importance of truth and honesty in science14 and wanted to transfer the culture of honorable research practice and moral values of scientific research to the students early in their education.
Students are also encouraged to read Lewis Thomas’ book of essays The Youngest Science: Notes of a Medicine Watcher for the discussion groups, so that they can appreciate the historical aspect of medicine as science but also compare the language of a literary essay and that of a scientific article. During the discussion groups, they read one of the scientific articles referenced in the appendix of Thomas’ book and relate it to the chapter where the author uses literary language to describe the same experiments. They invariably find the scientific language more difficult to read and understand, and focus their discussions on the reasons for the differences between scientific and literary language. Using these comparisons, the students learn that professional communication among scientists is short, unambiguous, and loaded with information, bursting with technical terms, and presuming knowledge of a particular, usually very narrow, scientific field. The opaqueness of scientific language to a lay reader (including medical students in preclinical years) contradicts the presumed transparency of scientific information and provides another stimulus for the students to develop a critical eye for the appraisal of scientific information. Thomas's essays emphasize that it is not only the language that makes an article scientific, but also the content, completeness, and manner in which the information is presented. At the end of the discussion session, the students have to give a short, three-minute talk about the aims, methods, results, and conclusions of the article discussed during the class, to experience the effort needed to make the message clear and simple yet also accurate.
After the course, we offer an elective to the students interested in doing scientific research. The topics are usually related to issues that are interesting to the students: their problems and wishes, education, and professional advancement. We advise students on the design of the study, analysis of data, and writing of the article. Most of the work done by these students gets published in a theme issue of the Croatian Medical Journal (see Table 2). In this way, students do research and publish papers that undergo rigorous scrutiny of international peer review, and our journal publishes a special issue with excellent papers each year. We have also established contact with students and their mentors from other countries and so far published reports from or about medical students from Bosnia and Herzegovina, Serbia, Albania, and Turkey (see Table 2).
Research Related to the Course
The students’ response to the course was overwhelmingly positive, with 96% during the first year feeling that the course provided important education in a stimulating way. They felt that they understood better the need for clarity and simplicity of scientific communication, and were better prepared for critical evaluation of the literature they read during the clinical rounds. These responses are typical of those we receive each year.
To evaluate the effects of the course on students’ knowledge of and attitudes toward science and research methodology, we planned several lines of research. First we assessed the attitude toward science in students entering medical school. They came with low knowledge on research methodology but positive attitudes toward science.15 We are currently following up this cohort of students to see possible changes in their attitudes during the six years of study. In a cross-sectional study of all students from the medical school in Zagreb, we showed that the knowledge on research methodology and attitude toward science was highest in students who just finished the course.16 Although our study was not designed to test causative relationship between the course and students’ attitudes, the results are encouraging—we are now doing an intervention study to see direct relationships between the course attendance and attitudes toward science. Because attitudes toward science and knowledge of scientific methodology were lower during the clinical study years,16 we are currently working with the school's administration on the vertical integration of the course with clinical courses from the fourth to the sixth year of study. We are also working on a long-term assessment of attitudes toward science among physicians finishing their primary residency and coming to our school for the national licensing examination.
Teaching medical students the principles of scientific research is a long-term effort, the effects of which will be visible in future. To answer the current needs of medical researchers, we transferred our educational activities with the journal authors to all potential authors, primarily young clinical researchers embarking on their academic careers. In 2002, we started a continuing education course called “Planning and Writing about Research in Medicine.” The topics are similar to those in the graduate course but the emphasis is on practical issues in planning research, analyzing data, and writing a scientific article. The course lasts for two days (17 class hours, mostly in practical exercises). We have had three such courses so far, and the satisfaction of the participants (83 so far) is high: mean 4.5 ± 0.7 points on a scale from 1 (not satisfied) to 5 (completely satisfied). The participants are mostly young academic physicians, and there are always more applicants for each session of the course than we can take. The course has been highly rated by the Croatian Medical Chamber, which serves as a relicensing body and evaluates all continuing medical education programs.
For academic physicians needing more advanced education in writing a scientific article, we have introduced an international writing course.8 The first course was organized in 2001, and now they have become a regular event, linked to an international public health meeting held each year in Croatia. We share running the course with our colleague editors of major international medical journals. The course is carried out in English and concentrates on teaching scientific writing skills. Again, the target population consists of young academic physicians, especially those who have done some research and are planning to write a manuscript. The participants come from all countries in southeastern Europe.
Following our experience, the three other medical schools in Croatia introduced a similar course into their curricula, so that scientific communication has become a part of all Croatian medical curricula. Our educational activities, both at the graduate and postgraduate levels, have a common goal: to increase the critical mass of academic physicians with skills for understanding, performing, and communicating biomedical research. In this way we hope to develop an evidence-based approach to practice and research in medicine, as well as critical-thinking abilities and critical appraisal skills during teaching of EBM. Finally, by teaching the principles of scientific research and fostering a positive attitude toward it among medical students and academic physicians, we hope to promote responsible conduct of research in the academic environment. Our next step will be the transfer of our experiences and knowledge to nonmedical research and teaching fields, and the development of similar teaching programs at the other schools at our university.
1.Marušić A, Marušić M. Small scientific journals from small countries: breaking from a vicious circle of inadequacy. Croat Med J. 1999;40:508–14.
2.Jonjić S, Lučin P. The science at Croatian universities: a gloomy view through SCIsearch and Medline. Croat Med J. 1996;37:2–6.
3.Frković V, Skender T, Dojćinović B, Bilić-Zulle L. Publishing scientific papers based on master's and PhD theses from a small scientific community: case study of Croatian medical schools. Croat Med J. 2003;44:107–11.
4.Dušek T, Bates T. Analysis of European medical schools’ teaching programs. Croat Med J. 2003;44:26–31.
5.Mišak A, Petrak J, Pećina M. Scientific biomedical journals in Croatia. Croat Med J. 2002;43:8–15.
6.Marušić A, Marušić M. What can medical journal editors do in war? Lancet. 2002;360(suppl):S59–60.
7.Marušić M, Marušić A. Good editorial practice: editors as educators. Croat Med J. 2001;42:113–20.
8.Marušić A, Mišak A, Kljaković-Gašpić M, Marušić M. Educatione ad excellentiam—ten years of the Croatian Medical Journal. Croat Med J. 2002;43:1–7.
9.Đanić A, Hadžibegović I, Loparić M. Status of women in small academic medical communities: case study of the Zagreb University School of Medicine. Croat Med J. 2003;44:32–5.
10.Borovečki A, Belicza B, Orešković S. Seventh anniversary of Andrija štampar School of Public Health: what can we learn from our past for the future? Croat Med J. 2002;43:371–3.
11.Zier K, Stagnaro-Green A. A multifaceted program to encourage medical students’ research. Acad Med. 2001;76:743–7.
12.Camba R. Millennium essay: start making sense. Nature. 2000;406:461.
13.Srinivasan M, Weiner M, Breitfeld PP, Brahmi F, Dickerson KL, Weiner G. Early introduction of an evidence-based medicine course to preclinical medical students. J Gen Intern Med. 2002;17:58–65.
14.Petrovečki M, Scheetz MD. Croatian Medical Journal introduces culture, control, and the study of research integrity. Croat Med J. 2001;42:7–13.
15.Vodopivec I, Vujaklija A, Hrabak M, Lukić IK, Marušić A, Marušić M. Knowledge about and attitude toward science of first year medical students. Croat Med J. 2002;43:58–62.
16.Hren D, Lukić IK, Marušić A, et al. Medical students’ attitude toward and knowledge about science and scientific research. Med Educ. 2003 [in press].
Medical Education in Croatia
In the tradition of the Central European education system, students in Croatia enter the medical school at the age of 18, after four years of secondary schooling. The admission criteria include the student’s grade-point average in high school and grades from chemistry, physics, and biology, as well as the score on a written multiple-choice admission test on these subjects. All four Croatian medical schools use similar admission tests, with about a 40% admission rate. Women predominate among medical students, with a stable 3:2 ratio since the 1970s.9 The medical curriculum lasts for six years, and the total number of class hours ranges from about 5,500 to 5,900.4 The curriculum is composed of core and elective parts, with a predominance (90%) of mandatory courses. Current reform at all four schools is oriented toward introducing vertical and horizontal course integration and modular/problem-based learning.