For the past 15 years I have practiced medicine narrowly, both in reference to my scope of practice and the amount of time I spend with patients. The majority of my time has been spent teaching medical students and doctoral (PhD) students. The contrast between teaching in these two worlds could not be greater. I know the details of my bioengineering doctoral students' lives, I know their goals, and I know their research. Most important, I can watch their progress as, over the years, they gain an understanding of the scientific method and the imperfection that is medical research. In contrast, the medical students I work with are like a great appetizer: They disappear too fast and leave me wanting more. During their one-month rotations with me, I learn a little about them, and before my memories of them can move to the long-term part of my cortex, they are gone. The exceptions to this rule are the medical students who come to me asking to be involved in my research.
Relationships are built into a PhD because earning one involves protracted (usually five years) study in a single area, with the centerpiece being a focused, mentored research project or doctoral dissertation. Whereas semester-long course work is usually part of the first two years, the remainder of time is spent on the dissertation. In contrast, graduating from medical schools without completing in-depth study on a single topic is not only possible, it is often the norm. Medical students frequently go from course to course and from rotation to rotation during their four years in school, with protracted study counted in weeks, not years.
Why is a dissertation part of doctoral training? Dissertations have been part of doctoral training for over a century.1 The Research Councils UK have set forth a number of goals that PhD training is meant to achieve.2 Almost all of these goals are relevant to the practice of medicine. A few prime examples include
* Development of original, independent, and critical-thinking skills;
* The ability to develop theoretical concepts;
* The ability to critically analyze and evaluate one's findings and those of others;
* The ability to identify and access appropriate bibliographical resources, archives, and other sources of relevant information;
* Demonstration of a willingness and ability to learn and acquire knowledge;
* The ability to demonstrate self-awareness;
* The ability to identify one's own training needs; and
The ability to understand one's behaviors and impact on others when working in, and contributing to, the success of formal and informal teams.
The rapid pace of research and the ever-changing practice of medicine would seem to indicate that the skills listed above are essential. If one believes that these skills are essential, then logical questions are as follows: Do current medical school curricula contain content to achieve these goals? Is achieving these goals in the relative absence of a longitudinal, in-depth learning experience possible? Is there something in the PhD curriculum worth emulating? If there is something worth emulating, what is it? What else does the medical school curriculum need to include?
This issue of Academic Medicine contains five articles that discuss scholarly projects (SPs) in medical schools. SPs, also referred to as scholarly concentrations, are elective or required curricular elements that entail in-depth study in a topic area. Although SPs can encompass classical research, they can also include medically related scholarly work that is not pure research.
Increasingly, medical schools across the country are instituting SPs as an integral part of the curriculum. SPs are thought to provide students with many of the skills advocated by the Research Councils UK. Additional potential benefits include providing role models, mentorship, and guidance for students regarding careers that integrate research, teaching, advocacy, and clinical service; increasing the number of students who pursue academic careers; and enhancing the medical school culture of self-directed learning. Despite the increase in these programs, there is little written related to the need for, implementation of, or outcomes regarding SPs. The articles in this special issue of Academic Medicine discuss these and other aspects of SPs as part of the undergraduate medical school curriculum.
SPs across the country are either required, like at the University of Pittsburgh School of Medicine (UPSOM), or elective, as at the Alpert Medical School of Brown University (AMS). The dichotomy between elective and required SPs raises questions related to the need for SPs as a curricular element. Are students who do not participate in elective programs at a disadvantage relative to their peers? Do SPs impact residency match? Do required research programs create problems for students and mentors when students who are forced to participate lack motivation? Parsonnet and colleagues explore these and other questions related to required versus elective programs.
To gain an understanding of the schools that currently have SPs as part of their curriculum, Green and colleagues surveyed faculty and administrators familiar with programs, and they provide examples of SPs at four medical schools. These examples include both elective and required curricular content, and they illustrate the growth in these programs.
Some schools, such as Duke, have long-term experience with required research activity. Laskowitz and colleagues discuss the program at Duke, which involves an immersive third year and has been in place for more than 40 years. They contrast this long-term experience with the program at Stanford, which has been in place for just over five years and usually entails longitudinal study across four or five years of medical school.
To provide some guidance for schools considering implementing SPs, I worked with a number of authors at the UPSOM and AMS to discuss the necessary elements for starting required and elective programs. We highlighted the need for an intensive structure to support a required program, and we discuss how integrating SPs into the curriculum has been an evolutionary process for both schools.
The ultimate goal, creating physicians with better analytic skills, is a difficult objective to measure. Unfortunately, few programs to date have incorporated rigorous methodology to allow outcome measurement. Bierer and Chen present a literature review on measuring the success of SPs. The authors present information related to what outcomes programs have measured to date, and they provide recommendations for better evaluation of programs in the future.
Measuring outcomes is difficult whether they are related to SPs or PhDs. However, the concept of mentored, longitudinal research as a fundamental teaching mechanism has a long and well-validated history in PhD studies. As we move to teach our medical students the analytical thinking skills critical to the practice of medicine in a rapidly changing world, there is much to learn and emulate from a PhD education. The articles in this issue should inform schools that have SPs or schools that are considering implementing them as a means to enhance their students' education.
Michael Boninger, MD
Dr. Boninger is professor and chair, Department of Physical Medicine and Rehabilitation, and associate dean, Medical Student Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.