Parsonnet, Julie MD; Gruppuso, Philip A. MD; Kanter, Steven L. MD; Boninger, Michael MD
Student participation in research or in-depth scholarship during medical school is conceptually appealing. Medicine, after all, is an ever-changing field with a seemingly infinite universe of remaining unknowns. It is axiomatic that the ability to understand and integrate new knowledge into clinical practice is a necessary quality of good physicians. Less clear, however, is the necessity that physicians be able to create new knowledge through research or be actively involved with research or other scholarly endeavors. Some have made convincing arguments that in-depth learning enhances students' educational experience.1 However, no data exist demonstrating that any level of scholarship in medical school leads to improved patient care or a more productive academic career.
Despite both the absence of proof that individual scholarship improves physician performance and the many hurdles that must be overcome to initiate research programs, medical schools are increasingly adding scholarly projects (SPs) to their curricula.2 For the purposes of this article, we define SPs as curricular elements that entail in-depth study of a topic area. SP elements range from mandatory, thesis-level research conducted over the course of a year or longer, to purely elective programs that can occur during a “research” month. Many factors motivate this curricular change: the belief that research experiences lead to better critical-thinking skills (be they applied to a research problem or to an individual patient), the desire of faculty to share with students the excitement of their particular research interests (and the stimulation of conducting research more generally), the belief that research creates skills and interest in lifelong learning, the belief that medical practice is changing so fast that the ability to critically evaluate research is a necessity for clinical practice, the interest in producing physician–scientists who can bring new discoveries to the bedside, and the sense that having an area of inquiry increases enthusiasm for a career in medicine.
The Association of American Medical Colleges Curriculum Directory reports 84 medical schools with “required research” and 9 additional schools with a thesis requirement. A review of each of these institutions' Web sites, however, yielded only 17 schools with required research—ranging from six-week unfunded experiences to multiyear funded experiences—and 44 schools that list elective research as a possibility; the remaining schools make no mention of research on their curriculum Web sites. This wide spectrum of research requirements stands in distinct contrast with the uniformity of other curricular elements. The variability leaves one wondering: What really are the benefits of required versus elective research? Here, we present educational and pragmatic perspectives related to requiring an SP for graduation. We discuss the following educational considerations related to a requisite SP: the theoretical benefits, the potential impact on applicants to a medical school, and the possibility of creating two tiers of students. The pragmatic considerations discussed include the costs to the medical school, the availability of mentors, and the possibility of a required SP leading to more time in medical school.
Potential educational benefits
The impact of any individual medical school curricular element on graduates' patient care skills is exceedingly difficult to document. Needless to say, then, no absolute proof exists that in-depth scholarship during medical school leads to better clinicians or physician–scientists. There are strong theoretical arguments, however, for benefits. Involvement in an SP likely improves the ability of a student to read the medical literature and understand its content. An SP by definition involves an in-depth literature review and analysis of existing data in an area specifically chosen by the student. Such personalized learning would reinforce and consolidate training in evidence-based medicine acquired in didactic courses or journal clubs. Additionally, mentored scholarly work may increase students' confidence in conducting their own investigations as clinicians and encourage a more substantial subset to enter academic careers. Although it is not essential that all physicians conduct research, it is essential that they have confidence to probe deeply into the clinical conundrums they encounter.
The premise that in-depth scholarship in a single area provides broad educational benefit is a basic underpinning of required master's theses and doctoral dissertations—universally accepted approaches to advanced education. Moreover, the need to continually read and update one's approach to patient care is mandated for retaining both medical licensure and specialty board certification; exposure to an SP may promote this behavior. The idea that hands-on activities contribute to an interest in lifelong learning has been one of the rationales for problem-based learning (PBL) curricula at many medical schools. SPs represent an expansion of this concept, generalizing PBL from patient care and applying it to scientific inquiry. We acknowledge, however, that despite many years of experience, no evidence substantiates that PBL enhances lifelong learning.3,4 Thus, medical educators may also eye the benefits of scholarship to physician practice with some skepticism.
Another theoretically positive educational benefit related to SPs is their ability to shape curricula. Many SP programs allow or encourage students to complete their scholarly work in an area of nontraditional study. Thus, SPs offer the possibility of shaping more comprehensive medical curricula from which students graduate with expertise in diverse areas of critical importance, ranging from the biological basis for major public health problems to health care reform. In studying discrete concentration areas, groups of faculty and students can be brought together around intellectual pursuits, forming academic communities.
For many SP programs, a stated goal is the creation of more physician–scientists. A dramatic shortage of physician–scientists exists at present,5,6 and some believe that physician–scientists are critical to creating translational research that directly improves patient care.7 Exposure to research makes medical students aware of this career choice, and this increased awareness may encourage more students to consider careers in research. This reason alone does not support a decision to require an SP for all students, but it remains a potential benefit.
Potential negative effects on education
Although the time commitment necessary to complete an SP varies from institution to institution, in all circumstances completion of an SP consumes hours that faculty and students could dedicate to other aspects of the curriculum. Transitioning to a required SP typically necessitates that material be pruned from the curriculum—a process that can be controversial and challenging. Although every curriculum includes redundancies which faculty could excise, removing material may come at the expense of student learning. Moreover, cutting course content does not necessarily absolve students from having to know the information. Rather, students may be forced to learn the material on their own, reducing their free time and, potentially, their understanding and retention of the knowledge or skills.
In many programs, completing the SP is a longitudinal process without a prescribed number of weeks or months of participation; students are expected to work on their project while simultaneously conducting course work or rotations. The SP may thus detract from a student's ability to study for an examination or read on a current patient. Yet, learning to juggle disparate obligations is also an important acquired skill. Clinicians and clinician–investigators routinely balance in-depth inquiry with clinical practice and other obligations (e.g., administrative, committee, and volunteer work; family and personal responsibilities). Learning this skill in medical school could prepare students for the real-life circumstances they will probably encounter as physicians.
Another potential downside of a required SP is that it may force some students to participate in an activity in which they have no interest. Although students may have little interest in other components of the curriculum, the nature of an SP—as a self-directed, longitudinal enterprise that involves a mentor—makes an unmotivated student particularly problematic. Voluntary mentors play a critical role in all SPs, and unengaged students may cause mentors to lose interest in working with medical students more generally. Furthermore, lack of interest or motivation may make successful completion of a required independent project less likely, undermining student confidence and potentially decreasing the uninterested student's enthusiasm for medicine in general. Optimally, the admissions process would weed out students opposed to conducting research, but assuming that all students understand the various curricula or even know their true interests before enrolling in medical school is naive.
Requiring an SP may also reduce innovation. Choosing a risky project or one that requires a larger-than-average time commitment might not appeal to students if they perceive that their medical student performance evaluation could reflect failure to complete the project or to complete it successfully, thereby lowering their academic standing and creating other disadvantages. Elective programs that provide students with the option to withdraw from a project without prejudice to their evaluations may contribute to an atmosphere in which students feel free to explore, innovate, and throw caution to the wind.
Requiring students to undertake SPs would not only affect the institution but would also have important effects—some positive, some negative—on individual students. One positive effect is the possibility that participating in a scholarly activity could result in publications and/or presentations that would improve a student's ability to match into a desired field and/or into a competitive residency program. Publishing research, according to some sources, positively influences selection into some highly competitive residencies8—although not in the primary care specialties (Parsonnet, unpublished data).
Schools with elective SP programs face the pedagogical and theoretical challenge of providing disparate educational experiences for their students. Any institution considering the implementation of an elective program must come to terms with the fact that only a portion of its students will produce significant scholarly output. Such an elective program may result in an unintentional two-class system: Faculty (and fellow students) may unjustly perceive students who conduct and publish or present scholarship as more academic than those who do not. Further, students with outputs may have an actual8 or perceived advantage in the residency match.
Required scholarship may also create an additional hardship for students who are struggling academically with other elements of the curriculum. Typically, SP programs allow students to delay their research while they tackle basic course work or clinical rotations. Repeatedly delaying work on an SP to remediate course work or to get through challenging courses, however, can lead to falling farther behind. These problems may not exist in a system in which students may drop the scholarly element (because it is elective) and concentrate on their core courses or clerkships.
Another potential consequence for students participating in a required SP is the potential need to lengthen their time in school. Students who go into greater depth in their study or students who are behind in completing a required SP may elect to step out of the required curriculum to conduct research, either as matriculated students (incurring tuition) or during a leave of absence. For some, this additional time spent on education may be a positive experience. The flexibility to take extra time before graduation, however, depends on the availability of financial support. Students who need to complete their education quickly to pay off college debts or to support families may find the extension of time in medical school financially burdensome or even untenable.
Medical School Admissions
A medical school's decision to incorporate an SP program—especially one that is required—into its curriculum will influence the admissions process. Students and applicants will likely view an elective SP program as providing additional opportunities. Aside from this positive perception, elective SPs are unlikely to cause major changes in the makeup of a particular school's applicant pool. A required SP, however, has the potential to have more dramatic effects—be they positive or negative—on applicants. A required SP may result in the recruitment of more focused students who come to the institution wanting to be part of a program that emphasizes scholarship for all. A required SP may also compel applicants to look at schools' research strengths and apply to schools where the faculty's areas of expertise match their interests. The benefits of such matching include enhanced mentorship, increased student–faculty contact, increased engagement of faculty in student learning, and an increase in the intellectual engagement that derives from a scholarly pursuit. Requiring research may also result in greater faculty interest in the admissions process.
Conversely, a required SP may cause some students either not to apply to a particular school or not to matriculate. Whether the loss of these applicants would be beneficial for an institution (i.e., few students uninterested in the curriculum would attend) or detrimental (i.e., some outstanding students may not apply at all) is not known. However, given the large number of student applicants to medical school, any negative effect is likely to be small. Yet, even small changes can alter overall class composition. For example, when Stanford made its SP program elective instead of required, it briefly observed an increased percentage of men accepting admission compared with women and a decrease in the number of students requiring financial aid. These changes were not reflected in the overall applicant pool (Parsonnet, unpublished data). These findings reflect only one school over a short period of time, and no school can accurately predict a priori the effects a required SP program will have. Nonetheless, changes in admissions related to scholarly programs warrant consideration.
Pragmatic Concerns: Costs, Mentorship, and Culture
SP programs—both required and elective—increase the costs of a medical education, influence mentorship, and affect institutional culture.
The costs of a required SP include stipends for research experiences, expenditures for research supplies and materials, salary support for faculty time, administrative costs, and funding for other needs (e.g., international travel for students pursuing global health projects or travel to research meetings). These costs—most of which are ongoing rather than one-time-only, start-up costs—can be considerable depending on class size and the duration of research activities. These costs apply to elective SP programs too, but elective programs require fewer resources to implement and sustain. Fewer faculty mentors need to be identified and compensated, fewer student projects require funding, and the administrative infrastructure needed for evaluation and to ensure compliance with program requirements is smaller.
Medical student research consumes considerable faculty time, both in mentorship and in academic advising. Although faculty may reap awards from this time tangibly through research output and intangibly through closer faculty–student relationships, students who are unenthusiastic about the research or who are involved merely because it is required can drain faculty time while proffering little benefit. At institutions with significant research capacity, availability of mentors may not be a problem. However, smaller institutions may not have the capacity to implement a required scholarly experience. We should note, however, that mentors do not necessarily need to be medical school faculty. Effective mentorship can also come from other health science graduate programs such as nursing, public health, or rehabilitation, and from programs external to the medical school such as the National Institutes of Health, departments of public health, nongovernment organizations, and even other universities.
In addition to creating potential financial and personnel challenges, requiring an SP constitutes an educational paradigm shift for the faculty and students of a school. Such a transition involves institution-wide acceptance that SPs are as important as basic science courses and clinical rotations. Such a recognition may not come easily at all institutions. In addition, establishing SPs requires developing new methods of performance evaluation. Further, the fact that some SPs require students to work during their free hours requires an acceptance from the faculty of the extra demands on student time. Starting an SP as an elective, rather than a required program, may permit faculty and students alike to discover whether such an approach to medical education is appropriate for their institution—without incurring the expense of making the concrete institutional commitment necessary to move the program forward.
Because completion of an SP is not a requirement for medical licensure, the choice to mandate scholarship must occur at the institutional level. Ultimately, an institution's decision to require an SP—or offer it as an elective—comes down to the fundamental beliefs of its faculty and to pragmatic considerations of costs in time and resources. In considering a required SP, each institution must address one basic question: Is in-depth inquiry an essential component of its educational mission?
If a faculty believes that the skills and knowledge students acquire through a scholarly experience are essential to its educational mission, then it must next address pragmatic questions related to the resources needed to require SPs of all students and the impact this requirement will have on the overall curriculum and culture. Required research commits an institution to meeting the needs of each and every student; the human and financial resources to do this may not be available at all institutions. If a faculty believes in the educational value, however, then working toward the goal of an SP requirement is an appropriate path. Pragmatism may dictate that the school consider its SP in broad context and begin by building, codifying, and solidifying elective programs before considering the much more demanding challenge of required scholarship. The article by Boninger and colleagues9 in this issue of Academic Medicine provides information on practical aspects of instituting an SP program.
Regardless of the approach chosen, it is imperative that any institution considering a new SP program collect data that can help determine the program's positive and negative effects. The article by Bierer and colleagues,10 also in this issue, provides guidance related to the types of measures that are appropriate. The evolution of the field of medicine requires that medical educators constantly and systematically look at better ways to prepare future physicians; the SP is one curricular innovation worthy of further exploration and investigation.