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A Multifaceted Program to Encourage Medical Students' Research

Zier, Karen PhD; Stagnaro-Green, Alex MD

Educating Physicians: Essay

Clinician-scientists are important members of a research community that has more opportunities than ever before to solve problems important to patients. Nevertheless, the number of physicians applying for and receiving grants from the National Institutes of Health (NIH) has dropped. Introducing medical students to research and relevant support mechanisms early in their education may help to reverse this trend. In 1995, the Mount Sinai School of Medicine created its Office of Student Research Opportunities (OSRO) to stimulate students to engage in research. It also appointed a new dean to direct the OSRO; the person who filled this new position was a senior faculty member involved in patient-oriented research. The OSRO advises students, identifies faculty who want to mentor students, sponsors the Distinction in Research program, organizes an annual research day, helps fund summer and full-time research, and has created an endowment to support student travel to national meetings. Between 1997 and 2000 the number of students who participated in the research day increased from 18 to 74, and the number of publications by the graduating classes increased from 34 to 58 between 1997 and 1999. Participants have presented both basic and clinical projects. The authors' experience has shown that medical students can be motivated to carry out research with appropriate encouragement from the administration and the faculty, something that may help to reverse a troubling national trend. Based upon these early successes, Mount Sinai is developing a novel five-year program to provide medical students with research training.

Dr. Zier is professor of medicine, immunobiology, and gene therapy and associate dean of medical student research; Dr. Stagnaro-Green is associate professor of medicine and dean for curriculum and academic affiliates, both at Mount Sinai School of Medicine, New York, New York.

Correspondence and requests for reprints should be addressed to Dr. Zier, The Mount Sinai School of Medicine, Box 1089, New York, NY 10029; telephone: (212) 659-9267; fax: (212) 369-3212; e-mail: 〈〉.

During the past decade there has been increasing recognition that the number of physician-scientists in the United States is decreasing alarmingly. Dr. Leon Rosenberg postulated in a recent article in Science that if the number of physicians applying for research grants from the National Institutes of Health (NIH) were to continue to decrease at present rates, by 2003 there would be no firsttime physician applicants for NIH support.1 He concluded that the data indicated that progressively fewer young MDs were interested in (or perhaps prepared for) careers as independent NIH-supported investigators. Indeed, within the last three years alone there has been a 30% decrease in the number of firsttime NIH applications submitted by MDs,2 something that could directly affect the ability of U.S. researchers to perform top-quality translational research as we enter the next century. Recently, it was reported that one of the things that correlated with residents' choosing academic careers was whether or not they had published the results of their research during their training.3 The Howard Hughes Medical Institute also has determined that students who receive research training fellowships for a year of full-time research are more likely to seek postdoctoral training after receiving their MD degrees than are those who do not, suggesting that time spent facilitating the process of undertaking research would be well spent.4 At the end of his Science article, Dr. Rosenberg made five recommendations for addressing the decline in the number of clinician-scientists; the first was that medical schools create an environment that attracts, fosters, and rewards students committed to research.

In 1995, the Mount Sinai School of Medicine created the Office of Student Research Opportunities (OSRO) to encourage students to do basic or patient-oriented research. Since its inception, the programs developed and overseen by the OSRO have been considerably expanded and refined to better meet student needs. Support systems have been developed to guide students to available research opportunities, help them to identify mentors, and inform them of funding sources. Mechanisms to reward their successes also have been instituted. Important starting points are that no previous research experience is required and that the faculty recognize the training of future medical researchers as one of their primary responsibilities. Opportunities for research were built into our new curriculum that was launched this academic year (2000-01) so that they no longer appear to be “added on” to required studies. Finally, an innovative Research and Medicine Program is being developed to train students who do not obtain the MD-PhD degree in research skills. Our goal is to prepare these students for positions that will further their development as independent investigators.

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The OSRO is located within the dean's office of the Mount Sinai School of Medicine, and is headed by the associate dean for medical student research, who devotes 35% of her time to OSRO responsibilities. The position is held by a translational researcher, which makes it easy for her to advise students and to place them with mentors. The physical proximity of the OSRO to other administrative faculty members increases the visibility of the office to both students and staff and helps to keep its existence up front in people's minds.

When the OSRO was established, its primary charge was to inform students about research activities and help them locate mentors. The OSRO has expanded its scope of activities over the past three years to meet the expressed needs of our students. It now coordinates all aspects of medical students' research activities, with the exception of those pertaining to students in the Medical Scientist Training Program (MSTP), which are handled by the graduate school. In this capacity, the OSRO acquaints students with the value of research to them, to society, and to their future patients; helps them to think “out of the box”; makes them aware of available research opportunities and encourages them to participate in projects; assists students in obtaining financial support from existing sources and developing new sources; implements mechanisms to reward student participation in research; and creates new and innovative programs. In the sections that follow we describe each of these activities in greater detail.

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During orientation on the first day of medical school, students attend a presentation on the importance of medical research and the activities of the OSRO. One month later a meeting, run by the director of the OSRO and attended by the medical school dean, is held for all interested students. Throughout the academic year meetings are held to inform different student groups about research opportunities in their areas of interest, especially those available in the summer and those enabling a year of full-time research.

Historically, medical students at Mount Sinai carried out research as an elective during the school year, during summer intersessions, or full-time when on leaves of absence. As of this year, they are able to devote a three-week block at the end of the first year to beginning projects that continue through the summer intersession. This extended period is highly attractive to the mentors and allows the students to perform more challenging studies.

Students are informed about available opportunities in a variety of ways. One-on-one meetings, scheduled upon the student's request, help students develop confidence and then navigate the steps required to begin projects. In September 1999, an OSRO Web site was built; it has proven to be the most convenient way to inform students about research-oriented functions. The site is accessible via the school of medicine's home page, 〈〉, and is divided into sections dealing with: (1) a description of the purpose of the OSRO and the programs it administers, (2) research opportunities within the school of medicine, (3) summer and full-time research opportunities at other institutions, (4) sources of funding, prizes, and awards, (5) information about scientific meetings for medical students, and (6) abstracts and publications by students in the previous year's graduating class. The diversity of projects and opportunities described is sufficiently broad that everyone can find something, regardless of his or her particular interest. Sometimes information about external programs is disseminated in the student newsletter, in flyers sent through interoffice mail, and by e-mail. Contrary to our initial fears that using so many media to keep students informed would constitute overkill, the students appreciate these efforts. We hope that making information easier to obtain will increase students' participation in intramural and extramural research activities and ensure that the choices they make are more informed.

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Students' participation in research activities requires funding. The development of various means to finance student research has been one of the highest priorities for the OSRO. Our goal is to provide support to every student interested in either carrying out a summer research project or doing fulltime research while on a leave of absence.

To this end, the OSRO has developed and coordinates several internal sources of funding to support students doing summer research projects at Mount Sinai. These are in addition to extramural funding obtained by students who have summer projects at other institutions. The initial source of funding came through a grant for Short Term Research Training, originally funded by the National Institute for Diabetes and Digestive and Kidney Diseases. In 1995 the dean's office began allocating funds at the same level of support. Fifteen students annually are supported through this mechanism.

The second source of funding is work study, a federally-funded program based on financial need. Eligible students are provided with funding to perform summer research with mentors of their choice. Over the last three years, between 23 and 40 students received funding through this program. Interestingly, between 1997 and 1999, the percentage of students who used work study funds to support summer research experiences increased from 57% to 77%.

Individual departments also provide support for students. The number of stipends varies greatly, since they depend largely upon resources of individual faculty members. Last year, 37 positions from 14 different departments were offered to students.

A fourth source of funding was created in 1994, the result of a $500,000 endowment for medical students to perform interdisciplinary research projects over the summer. The endowment supports research projects that encourage collaboration among health care providers from medicine, nursing, and social work and funds 12-15 students each year.

Our final source of funding was created in 1999 by the Mount Sinai School of Medicine Alumni Association. The funding was an outgrowth of the Alumni Association's continued commitment to supporting student programs. Twenty-five thousand dollars a year were pledged for five years. This will provide funding for an additional ten students annually through 2004. Most recently, during the development of the new curriculum, department chairs pledged to provide the funding necessary to support the research of all first-year students with approved projects during the summer.

As the OSRO expanded, we became aware of two other funding needs. First, students presenting their data at national and international meetings needed money to cover travel expenses. A $100,000 endowment was created to provide this support. The money is distributed in the form of Research Presentation Travel Grants in the amount of $500, which must be matched by the student's mentor, and are available to any student who is first author of a research project that will be presented at a scientific meeting. Second, money was needed to support the increasing number of students who expressed interest in taking a one-year leave of absence to do full-time research. The dean's office awarded a Teaching Enhancement Grant to the director of the OSRO, which provides partial support for a limited number of interested students. We are now seeking to augment these resources by obtaining federal and/or corporate funding.

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Formally recognizing and rewarding students' involvement in research is critical to our program. A reward system shows that we truly value research, and provides us with a way to monitor the progress of students' research efforts. We recognize students' achievements in research in three ways: the Distinction in Research Program, the Medical Student Research Day, and recognition in the dean's letter.

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Distinction in Research Program

The Distinction in Research Program was designed for students who want an in-depth research experience. Proposals cannot be a part of any required research effort and the publication of case reports or literature reviews and projects in which the student performs a purely technical function do not qualify. In addition, students enrolled in the MSTP program are ineligible. To be admitted to the program, a student must submit a proposal, accompanied by a letter from his or her faculty mentor, stating that (1) the proposal has scientific merit, (2) the proposal was written primarily by the student, and (3) the student will be first author on any paper submitted to a peer-reviewed journal reporting the results. The last point implies that the student has carried out the majority of the experiments him- or herself and has taken primary responsibility for writing the manuscript. An OSRO advisory committee helps the student to develop the research proposal and follows his or her progress. This committee makes the final decision as to whether the proposal is acceptable. Students who fulfill the requirements have this mentioned in the graduation program and receive diplomas at commencement stating that they have graduated with “Distinction in Research.”

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Medical Student Research Day

The annual Medical Student Research Day highlights the importance that the school places on research, gives students the opportunity to present their work to the Mount Sinai community, and allows them to develop skills in data presentation. On that day, classes for first- and second-year students are canceled to encourage participation; students in the clinical years are urged to attend by clerkship directors. Faculty attendance is promoted as well. Students submit abstracts on their research, which are ranked by a faculty committee and published in the Research Day Program. The day begins with a keynote address by an invited speaker and is followed by oral presentations by the four students whose abstracts were scored the highest. These students each receive a $250 prize. All students who submit an abstract participate in a poster session, during which a buffet lunch sponsored by the Mount Sinai Alumni Association is served. Participation in the research day has grown. In 2000, 68 students presented their research, compared with 18 in 1997. The majority of students who participate are in their second year, since they have a long summer intersession to initiate a project. It is rare that first-year students have sufficient time to obtain data before the abstract due date in mid-December. We are now working to encourage more third- and fourth-year students to participate in the program. Students' interest in taking a leave of absence and doing a year of full-time research is growing, and since full-time research is done after the third or fourth year, this will increase the number of advanced students who participate. We have been especially glad to see an increase in the percentage of women students represented at the research day, which has grown from 28% to 49% in three years as a result of directed outreach efforts. Similar efforts are planned for underrepresented minority students.

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Recognition in the Dean's Letter

Prior to 1996, ranking of our students in the four categories that we use in the final paragraph of the dean's letters (good, very good, excellent, and outstanding) was based solely on performances in third-year clinical clerkships. Until that time, recognition of a student's participation in research in the dean's letter consisted of a description of the research and a list of any published abstracts and papers. In 1997 a point system was created that includes performance on USMLE Step 1, honors in clerkships, leadership positions in the school and community, and the publication of research abstracts and/or manuscripts. Of a maximum total of ten points achievable, two (20%) are obtainable through publishing papers and presenting abstracts. Since 1997, the number of peer-reviewed publications has increased from 37 to 61. The inclusion of research productivity in the algorithm was meant to convey the importance assigned to research activities and to reassure students that their efforts will be recognized in an important way.

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We plan to build on our successes to date and address the interests of even more students by expanding the activities of the OSRO.

One new program, the Research Integrative Core, is being offered for this first time this academic year (2000-01) as part of Mount Sinai's new medical school curriculum. The Research Integrative Core is a three-week elective block offered at the end of year one that can be used for in-depth clinical or research experiences.

As this block of time is contiguous with the ten-week summer break, there will actually be a total of 12-13 weeks available for research. The major goals of the Research Integrative Core are to provide students with an introduction to the role that research plays in a physician's career and to teach them about the relationship between the scientific method and advances in clinical medicine. Many of the students who select the Research Integrative Core already have initiated research projects as electives. In all cases, participation is limited to those who will continue working on their projects through the summer. Many will continue their work in the second year, and some will enter the Distinction in Research Program. While students who participate in the Research Integrative Core will spend the majority of their time working on their projects, mentors are urged to help them see how what they are doing might be related to the delivery of medical care. In addition, students will be encouraged to participate in conferences and journal clubs, as well as make rounds or attend clinic to see patients with illnesses related (even indirectly) to their projects. Mentors who are not clinicians can work out arrangements with clinical colleagues so that their students can enjoy the clinical flavor of the experience. A brief didactic component, designed to provide a practical and theoretical structure to the laboratory experience, will be offered as well.

A second, novel program, entitled Research and Medicine, also is being developed. This program will offer research training to students who are committed to obtaining advanced research training and experience, but who do not plan to obtain a PhD. Candidates for this program will be students who enter medical school with a special interest and/or expertise in research. They will complete a number of research blocks during the four years of medical school, receive special training in research methods, design, analysis, and ethics, and be encouraged to take a tuition-free year, devoted to research, following their second or third year. Some of the planned activities include a translational research journal club that emphasizes work begun in the lab and brought to the “bedside,” meet-thepreceptors dinner sessions in which clinician-scientists present their work, and work-in-progress sessions featuring student presentations.

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Over the last five years, we have developed an active and expanding program that offers a diversity of research opportunities to medical students. Our aims are to broaden the way in which students think about the complex problems they will face in their clinical work and to promote the development of future clinician-scientists able to help bridge the gap between scientists and physicians. The OSRO has been successful in increasing the number of medical students who participate in research, present abstracts at national meetings, and publish articles in peerreviewed medical journals. An annual Medical Student Research Day, the Distinction in Research program, and special recognition in the dean's letter all provide positive reinforcement for students' involvement in research. A special endowment dedicated to support student presentations at national and international meetings has allowed our students to interact with researchers from around the world. Finally, new and innovative programs are being developed and introduced.

Many factors have contributed to the growth of our program. The administration's allocation of dedicated funds and space for the OSRO and the dean's emphasis on the importance of the initiative for both students and faculty have been crucial. Finally, the commitment of a dedicated and inspiring director, the enthusiasm of our faculty to serve as mentors for student-researchers, and the eagerness of our students to participate were all critical ingredients in our success.

However, certain challenges remain. We are continually striving to entice more students to become involved in research, to develop programs that enable students to work on projects that lead to publishable results, to develop added funding mechanisms to support students who want to do full-time research, and to involve more faculty as research mentors. Furthermore, although it is too early to undertake such studies yet, we need to develop a longrange tracking system to determine whether we are successful in graduating increasing numbers of students who continue to dedicate components of their professional careers to research. We believe that the OSRO can respond to many of the problems associated with the rapid and alarming decline in the number of physician-scientists.1,2 As programs such as ours are developed and become known by students, they may well influence the students' perceptions of what a physician does. We look forward with anticipation to the continued expansion of our program, as well as to the development of other initiatives across the country that are directed to restoring the prestige and desirability of a career as a physician-scientist.

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1. Rosenberg LE. Physician-scientists—endangered and essential. Science. 1999;283:331–2.
2. Nathan DG. Clinical research: perceptions, reality and proposed solutions. JAMA. 1998;280:1427–31.
3. Schultz HJ. Research during internal medicine residency training: meeting the challenge of the residency review committee. Ann Intern Med. 1986:124:34–2.
4. Perpich JG. Physician-scientists: staying alive. Science. 1999;284:591–2.
© 2001 Association of American Medical Colleges