Modern medical training has established the goal that physicians should excel in the acquisition of clinical skills and knowledge and also understand how such knowledge is derived. The goal of many academic institutions is to train future physicians who will be engaged in new discovery and innovation as well as in the practice of medicine. It is in the spirit of creating future leaders of medicine that the Duke University School of Medicine (SOM) and Stanford University SOM began their scholarly research programs which emphasize disciplined research. We herein describe the origins of the programs at these two medical schools and how they have evolved over the years.
History of the Scholarly Programs
The scholarly research programs at Duke University SOM and Stanford University SOM both have roots dating back more than 40 years. The premise of the faculty members who founded the programs was that research training would provide an investigative counterpart to traditional instruction, broaden students' scientific training, and recruit students to careers in academic medicine. Both of these schools' scholarly research programs have evolved over time to provide more diverse scholarly choices for students, and the programs at both schools have grown since the 1960s, each surviving several cycles of curriculum reform.
Duke University SOM
The idea of a formal period of research training at Duke dates to 1959, when the chair of biochemistry, Philip Handler, proposed an intensive nine-month research training period following the initial two years of basic science instruction for students interested in becoming clinician investigators. The first portion of this training period was primarily didactic and focused on gaining the knowledge necessary to perform basic research. The latter half of the research experience involved designing and implementing an independent research project under the direct supervision of a faculty mentor. The history of the research experience at Duke has previously been published1–3; components key to this article include a curriculum modification in 1962 that allowed students to enter the research year after a year of clinical rotations, and the curriculum revision of 1966, which incorporated research training into the basic science elective time. By experiencing clinical training prior to the research experience, students were better prepared to understand the clinical and translational potential of their research projects. This philosophy still guides the third-year research program. Although a longitudinal practice course is incorporated into the medical school curriculum, Duke's curriculum still primarily follows a one + one + one + one format: Students learn basic sciences in their first year; they experience clinical clerkships their second year; they undertake intensive research (the topic of this article) during their third year; and then they rotate through clerkships again in their fourth year.
As the dedicated research program grew in the 1970s, multidisciplinary tracks were created to thematically integrate basic science courses with research areas. As the opportunities for students became more diverse, management of the third year became more cumbersome, and Duke faculty and administrators divided the third-year program into study tracks to aid in the approval of mentors, the review and approval of student research/project proposals, and the evaluation of students' performances. Although the nature of these study tracks evolved somewhat over the next 10 years, the fundamental structure and content remained largely unchanged (List 1). Requirements for the research year became more formalized and eventually included completion of a formal thesis. Two curricular reform processes initiated in the late 1990s and in 2004 reaffirmed the importance and value of a dedicated period of scholarly research.3
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Table: List 1 Evolution of the Study Programs at the Duke University School of Medicine, 1998–2008
Stanford University SOM
Stanford has had a long tradition of encouraging medical students to engage in scholarly research. In 1959, the school moved its clinical training site from San Francisco to the main university in Palo Alto, California. Along with a new physical environment came a new curriculum, the “Five-Year Plan,” which the school introduced to foster a climate of graduate education. Students matriculating with prior bachelor's degrees spent an extra year in medical school, whereas some undergraduates were admitted after three years of baccalaureate training and received a joint BA/MD degree at the end of five years of medical school. Many students in the Five-Year Plan spent the extra year engaging in basic science research.4(p146–148) In 1968, the school changed to an “all-elective curriculum” that continued until 1982.4(p148–153) As implied by its name, the all-elective curriculum did not require students to complete specific basic science courses but only to pass Step 1 of the United States Medical Licensing Examination (USMLE).4(p148–153) This curricular freedom, combined with the establishment of the first National Institutes of Health (NIH)-funded medical scientist training programs, provided a pied piper's call for students interested in research. By mid-1974, two thirds of Stanford medical students were participating in some form of research activity by graduation, and 40% had authored or coauthored at least one publication during medical school.4(p154) This strong tradition of medical student scholarship continued from 1982 to 2003 even though the SOM reinstated a robust required curriculum (in 1984). During this same period, approximately 80% of medical students received funding to support their research for at least one academic quarter, and the majority of students elected to spend five or more years in medical school, although they could have potentially completed the curriculum in four years. Thus, in contrast to the program at Duke SOM that emphasized an immersive third year devoted to scholarship and from which most students graduated after four years, Stanford encouraged multiyear, longitudinal exposure to research, and a majority of students stayed for a fifth year of funded study. By 2003, however, a growing number of faculty at Stanford expressed concerns that students lacked adequate mentoring during their research time and that the school needed a more structured program of didactic course work, thematically linked to hypothesis-driven research. Thus, in 2003 Stanford introduced a new medical school curriculum that transformed the research element into a required component of each student's learning experience.
Evolution of the Scholarly Programs
The scholarly programs have evolved over time at Duke and Stanford as new research programs have emerged and the interests of students and faculty have changed. The early versions of both programs were focused primarily on laboratory-based investigation. Although laboratory-based research opportunities continue to be popular, many medical students today seek more diverse experiences in disciplines such as clinical research, community engagement, health policy, and biomedical ethics. Further, many students at both schools decide to pursue master or doctoral-level degrees after their initial introduction to research in these programs.
Duke University SOM
Since its inception, when faculty first proposed dedicated research training, the scope of Duke's third-year scholarly experience has adapted to reflect changing student needs and a shifting research environment. The third-year experience was originally designed in the context of laboratory-based, basic science investigation, but translational and clinical research experiences have become increasingly attractive alternatives for many students (Figure 1A). Although performing clinical research is consistent with the goals of the third-year curriculum (i.e., providing an investigative counterpart to traditional instruction, broadening students' scientific training, and recruiting students to careers in academic medicine), the increased proportion of students interested in patient-oriented research has also raised several concerns. For example, the path to obtain formal, laboratory-based training is well established, but traditionally there has been a paucity of programs incorporating formal didactic training in the conduct of randomized clinical trials. To address this gap, Duke offers a Roadmap Scholarship in Clinical Research, which, in addition to a mentored clinical research project, includes didactic coursework in the Clinical Research Training Program (this program is designed primarily for clinical fellows and medical professionals, but it is open to medical students as well). Roadmap Scholarship students conduct their research during their third year, although they may elect to extend the experience an additional year. The one-year program includes a mentored research project and core courses in biostatistics, research design, and the responsible conduct of research. Two-year Roadmap Scholars have the opportunity to take additional courses leading to a master's of health sciences in clinical research degree. These increased opportunities to engage in clinical research, implemented in response to student interest, coincide with the shift toward more clinical and less basic science research from 2005 to 2009 (Figure 1A).
Figure 1.:
Distribution of medical students by chosen field of study at Duke University School of Medicine (top) and Stanford University School of Medicine (bottom). For this analysis, the authors grouped the study programs at Duke and the scholarly concentrations at Stanford in an analogous manner to permit comparison.
The increased number of students involved with patient-oriented and clinical research has raised several challenges. The goals of the third year are more consistent with hypothesis-driven therapeutic interventions that require clinical research design and analytic skills, as opposed to observational or empiric studies. However, the compressed time frame may make it difficult for students to design and implement a meaningful clinical research project. For this reason, students may elect to incorporate an additional year of research, as described above. Thus, a spectrum of clinical research is acceptable for the third-year program, and the Third Year Committee (a group of faculty who oversee Duke's scholarly research program) strives to ensure that students are undertaking rigorous, hypothesis-driven clinical research projects that incorporate bioanalytic and research design skills, and that they are receiving supervision by faculty mentors who have formal training and leadership experience in clinical research.
Another challenge has been allowing enough dedicated time for students to fully realize the goals of the research program. As originally designed, the third-year experience lasted 8 to 10 months. Just before the 2004 curricular revision, the experience was expanded to encompass a minimum of 10 months and allow for 12. However, for many students conducting patient-oriented and laboratory-based projects, even a 10- to 12-month experience may be too brief to accomplish meaningful objectives. Realistically, dedicating additional research time within the scope of a four-year medical curriculum is difficult, but students have several opportunities to extend their research training. In conjunction with Duke's Medical Scientist Training Program, several MD/PhD slots are reserved for second- and third-year medical students, thus allowing these students to continue a more rigorous research program culminating in a doctoral degree at no additional cost. Students may also elect to pursue an additional year of research without incurring a tuition charge for the extra time.
Another trend in recent years has been the increasing proportion of students pursuing a second professional degree during their third year. In the past five years, approximately 15% to 20% of students completed a dual degree. If the educational program for a second degree is thoughtfully integrated into the medical school experience, a second degree is compatible with the third-year mission of imparting a skill set that will prepare students to become future leaders in medicine. Traditionally, the majority of students have elected to complete the master's of public health degree at the University of North Carolina. Other options include a degree in business administration, library and information science, public policy, psychology, or law. Students completing dual degrees are subject to all of the requirements of traditional third-year students, including completion of a research project culminating in a thesis or thesis equivalent.
Study-away opportunities have also become increasingly popular, and in recent years, up to one-third of students elect to perform the majority of their third year at institutions external to Duke. The Third Year Committee provides oversight for students' study-away experiences and is responsible for reviewing and approving each study-away student's research environment, non-Duke-affiliated mentor, and research plan. Moreover, in conjunction with the study program director (one faculty member is responsible for each study area program or track), an assigned faculty member follows up with study-away students to ensure that they are making adequate progress. Although study-away locations are quite diverse, over the past five years, the most popular have been the University of North Carolina at Chapel Hill (n = 45); the NIH (n = 38); the University of Pennsylvania and Harvard (n = 5 each); Columbia (n = 4); the University of California, San Francisco and Stanford (n = 3 each).
One of the founding principles of the third-year program has been to increase the number of students who pursue academic and/or teaching positions. Recent modifications to the third-year curricular requirements have been designed to impart the skills necessary for embarking on an academic career. For example, in lieu of a thesis, students may submit a first-authored manuscript to a peer-reviewed journal, or they may complete an NIH training grant. A publishable product is not necessarily an expectation of the third year—even most students participating in exceptional research fellowships, such as the NIH Clinical Research Training Program or the Doris Duke Clinical Research Fellowship, do not have a publication at the end of the research year.5 However, nearly two-thirds of Duke graduates publish at least one scholarly, peer-reviewed article during medical school.3 Although a grant submission and first-authored, scholarly manuscript are often more labor intensive and require more faculty guidance than the traditional thesis, they can provide important initial experiences in grant and scientific writing that will ultimately help facilitate a student's transition to an independent faculty position. Duke also encourages all students to practice their public speaking skills to enable them to articulate their ideas effectively. Third-year students must present their research at the institution-wide Alpha Omega Alpha (medical student honor society) research symposium (described briefly below), and they are also strongly encouraged to present at regional or national conferences.
Despite the focus on advancing academic careers, a substantial proportion of graduating students may eventually pursue medical careers that are primarily clinical. Thus, an important objective of the third year is to impart basic skills in statistics and evidence-based medicine that will allow practitioners to read the clinical literature more effectively and better understand the scientific basis for medical clinical decision making. To address these needs, a statistics requirement was introduced as a third-year requirement. The redesigned statistics course includes didactic lectures and allows students the opportunity to directly interact with biostatisticians to discuss their research projects. An evidence-based medicine course is also being implemented to facilitate the incorporation of these statistical concepts into medical decision making.
Stanford University SOM
The new medical curriculum, which Stanford introduced in 2003 as part of its most significant curriculum change in more than 20 years, featured greater curricular integration, more efficient use of the classroom (evidenced by an approximately 25% to 30% reduction in lecture-based class time), greater instruction dedicated to the psychosocial aspects of medicine and the acquisition of clinical skills, and increased early patient exposure. An important feature of the new design was an emphasis on discipline-based courses (e.g., anatomy, genetics, molecular biology) at the beginning of the curriculum in order to establish a scientific foundation, followed by courses integrated by organ system in physiology, pathology, pharmacology and therapeutics, pathophysiology, and microbiology. Stanford SOM also added more robust clerkship requirements to strengthen clinical training.
The most innovative aspect of the new curriculum, however, was the introduction of required scholarly concentrations—programs to encourage closely mentored, in-depth, scholarly study in an area of student interest and faculty expertise. The concentrations were in many ways an extension of Stanford's tradition of encouraging student research and scholarship. Rather than being voluntary and ad hoc, however, the new concentration program required satisfactory completion of specific courses and submission of a scholarly work, typically a scientific paper or abstract, a position paper, or a comparable product appropriate to the field of study (e.g., a community needs assessment plan and presentation for Community Health, a presentation of an ethical dilemma and the framework that might be used to develop an ethical resolution for Biomedical Ethics, or a short story, book, or photo journalistic essay for Medical Humanities).
The fields of study that Stanford accepted as scholarly concentrations were chosen initially through a competitive process, similar to the NIH format for a “Request for Application.” Faculty submitted many more proposals for concentrations than the SOM could accommodate. The primary criteria for acceptance of a scholarly concentration were interest to students, methodologic focus, faculty commitment, and the availability of special SOM research capabilities that could add depth and allow for faculty expertise. Stanford promised each accepted concentration a modest amount of faculty and administrative support. The number of academic units required to meet the requirements of the scholarly concentrations was established as 12 (where one unit represents approximately 10 hours of class instruction during a 10- to 12-week academic quarter). Twelve units is fewer than the number students typically complete in one academic quarter and only 5% of the more than 240 units required for the MD degree. Thus, the minimum course requirements of the scholarly concentration were modest—far fewer, for instance, than the number required for an undergraduate major. Further, the hope was that students' initial immersion into research, as required to complete these minimal requirements, would serve as a catalyst for them to pursue future studies.
List 2 shows the original concentrations chosen for the Stanford program in 2003 and their evolution to 2008. Several of the scholarly concentrations at Stanford merit special attention. The concentration in bioengineering takes advantage of the new multidisciplinary Stanford Department of Bioengineering, which formed at the same time as the scholarly concentrations. This department supports engineers from the School of Engineering and physician–scientists from the SOM who hope to apply engineering applications and methods to biomedical problems. The bioinformatics scholarly concentration similarly combines and applies Stanford's capacities in computer science, genomics, and medical decision making. The concentration of biomedical ethics and medical humanities originated from two separate proposals by faculty who merged to create a sufficient nucleus of interested scholars (faculty and students) working together. Figure 1B shows student choices of scholarly concentrations at Stanford from 2005 to 2009. Notably, the percentage of students engaged in basic science research has varied between 30% and 45% of students and is at a lower level compared with Duke; however, the percentage of students involved in research in ethics and medical humanities has been higher (7%–15% of students) compared with Duke, most likely because of student recruitment by faculty interested in these areas.
Table: List 2 Evolution of the Scholarly Concentration Programs at the Stanford University School of Medicine, 2003–2008
Since the design of the new curriculum, required courses have not been scheduled on Wednesdays in order to allow students to take electives for their scholarly concentrations. In addition, starting in the spring of the first year, two additional afternoons each week are free of required courses. These scheduling features permit students to complete the course work for the scholarly concentrations during the first two years of medical school.
Many Stanford students—like their Duke counterparts—have embraced the initial research exposure provided by their scholarly concentrations to pursue master's and doctoral degrees in related fields of study. For instance, the concentration in health services policy research provides entrée to the master's program in health services research; the clinical research concentration includes course work that students can apply toward a master's degree in epidemiology; the community health concentration provides academic credit toward a master's degree in the School of Public Health at the University of California, Berkeley; and work in the molecular basis of medicine concentration can lead to a PhD in one of the basic science areas, either within or outside of the NIH-sponsored Medical Scientist Training Program. Approximately one-fourth of MD students graduating in the class of 2008 had completed additional master's or doctoral degrees as a result of their involvement in a scholarly concentration.
Planning and Advising Students in the Pursuit of Scholarly Programs
To pursue a scholarly project and simultaneously complete customary requirements for the medical degree is often challenging for students. Duke and Stanford have both implemented advising programs to guide students in their choice of concentration, to ensure that students are making suitable progress, and to resolve other problems that may arise. The experience at both schools has been that the success of research is dependent on achieving a good match between student and faculty mentor with regard to both research interests and temperament. The willingness of faculty both to guide students to an appropriate project and to devote themselves to active mentoring is vital to the success of students' projects. The ability of students to multitask—to succeed in medical studies and to dedicate themselves to a research enterprise—is equally vital to the success of the research partnership.
Duke University SOM
Appropriate planning is integral to the success of the third-year research experience at Duke and begins soon after students matriculate. A formal informational session is held at the end of the first semester in year 1, and this is followed in the spring by the Third-Year Fair, at which study program directors describe the breadth of ongoing basic and clinical research in their fields. The pairing of compatible mentors with students is essential for the success of the Duke research experience, and the SOM facilitates a good match through a number of means. Although students have access to an online mentor-match program, Duke emphasizes the importance of personally meeting with the study program directors, as they have firsthand and up-to-date knowledge regarding both the different types of research within their field and the different styles of their faculty. Study program directors then suggest—based on students' preferences regarding such factors as type of research, lab size, and mentoring style—individual faculty with whom students may discuss their research interests. Because mentor matching is such an important part of the third-year process, Duke has formally evaluated how students make their choices. Data from the most recent graduating class (2009) suggest that for approximately 15% of students, interaction with the study program director or mentor-match Web site was the primary determinant of their mentor selection. Approximately half of the students chose a mentor either on the basis of their first- or second-year interactions with faculty or by following the advice of upperclassmen. Duke encourages students to begin meeting with the relevant study program director and to interview prospective mentors and labs in the fall of their second year. Students must finalize their third-year plans by the end of April of year 2.
Given the highly individualized nature of the third-year research experience, the commitment of faculty mentors is central to the success of the program. To optimize positive research experiences, the Third Year Committee individually approves mentors. Prospective mentors discuss their interests with the appropriate study program director. Approval to serve as a mentor is based on each faculty member's track record of productivity, his or her commitment to mentorship, and his or her access to sufficient resources to optimize students' research experiences. Although mentors do not receive direct compensation for working with medical students, the departments of laboratory-based mentors are credited financially to help compensate for lab supplies and overhead.
Study program directors also play an essential role in the research program. Ultimately, they are each responsible for the success of research experiences within their study area. The role of the study program director starts in the student's first year; they facilitate appropriate matches between interested medical students and compatible faculty. The study program directors also serve as medical student advocates, and they gauge student progress by meeting with students in their program throughout the year. Although Duke does not mandate the frequency and nature of study program directors' interaction with students, experience has shown that meeting with students often and early is important, particularly for identifying and remediating any interpersonal or research problems in time to optimize a struggling student's research experience. The study program directors also present prospective mentors to the Third Year Committee, help to evaluate prospective study-away experiences, and track the progress of study-away students within their study areas. Study program directors also play a primary role in grading students' theses and helping to set policies within their study areas.
Although research experiences may vary widely, all third-year students must complete a series of core requirements. Every student is required (1) to complete a series of modules on the ethics and requirements of good clinical practice when performing patient-oriented research, (2) to demonstrate proficiency in biomedical statistics, and (3) to present his or her research to the Duke medical school community or at a regional or national meeting. Students must also submit a written thesis or thesis equivalent, such as an NIH training grant or a first-author manuscript submitted for publication, as described previously.
The research training period lasts from 10 to 12 months, as determined by the student and his or her mentor. In general, students devote the last three to four weeks of the research period to completing the thesis or thesis alternative, as well as preparing for Alpha Omega Alpha Day, an institution-wide event in which students present their research in platform or poster presentations. One trend over the past several years has been an increase in the number of students who elect 12-month research experiences. In 2009, 70% of students were engaged in research experiences lasting at least 12 months. In part, this trend is driven by an increasing number of students applying for scholarships, some of which require 12 months of research, to help fund their year. Approximately one-third of all medical students receive intramural or extramural scholarships to help finance their research experience. Thirty-eight percent of students (38/100) received scholarship support for third-year activities in 2009–2010, 40% (38/95) received funding in 2008–2009, and 41% (42/103) received funding in 2007–2008. This research support plays a significant role in helping students offset tuition and other expenses, which results in a significant reduction in the average debt of Duke graduates.
Stanford University SOM
The introduction to the scholarly concentration program at Stanford begins during the admissions process. As part of the supplemental application, students are asked to review a list of scholarly concentrations and to describe reasons why one or two may be of interest. Students are introduced to the scholarly concentrations by various mechanisms at the very beginning of their medical school experience. In the early years of the program, a scholarly concentration “fair”—staffed by scholarly concentration directors and prior-year concentration students—occurred one afternoon during student orientation. In recent years, noon-hour luncheons which occur over the course of several weeks have replaced the fair. The noon-hour sessions allow each director more time to address the entire medical school class. These introductory events allow students to meet the scholarly concentration directors and prior-year students who have chosen a particular concentration. The prior-year students often serve as “near-peer” mentors, that is, students who have embarked on, or recently completed, a scholarly concentration and can advise new students about its pros and cons. In addition to these information sessions, most concentrations offer an introductory course early in the first year during which students meet faculty members affiliated with the concentration and learn about their areas of research interest. In turn, faculty members often use these courses to recruit students interested in joining their research teams. Students must declare their choice of scholarly concentration by October 1st of their second year.
Once students have chosen a scholarly concentration, they are expected to stay in close contact with the concentration director and project mentor. Most concentrations have two components: didactic (course) work and a scholarly project. Students typically complete didactic work in Years 1 and 2 of medical school, while the completion of their scholarly project commonly extends through the clinical years. Both the course work and the scholarly project are graded on a pass/fail basis, although students' scholarly concentration accomplishments appear prominently in their medical school performance evaluations. In addition, abstracts, publications and other tangible products of the scholarly concentration are sources of student pride, and students perceive them as having significant value for enhancing competitiveness to residency programs.
Students attend mandatory, twice-yearly, 45-minute appointments with the associate dean for student affairs in charge of student research (P.C.C.) who supervises the choice of concentration, gauges yearly progress, provides advice about summer research, and gives feedback on proposals for Medical Scholars funding. Thus, three major faculty resources are available to advise students about their potential choice of concentration: the individual scholarly concentration directors, the director of the scholarly concentration program who has oversight of the entire program, and the associate dean for student affairs who has oversight of all research opportunities that involve medical students. Close faculty oversight and involvement may explain the rapid growth in the number of funded student research proposals from 95 in 2002–2003 (prior to the required scholarly concentration program) to 176 in 2007–2008. Approximately 80% of student research proposals were funded during the 2008–2009 academic year.
In addition to helping students choose their concentration, scholarly concentration directors help ensure that students stay on track by meeting with them periodically, assessing progress in both their course work and scholarly project, and helping to troubleshoot problems that arise. Faculty members who supervise students in the scholarly concentration program receive funding by earning “teaching-effort course units” from the tuition pool for student course work and supervised research. The tuition dollars that accrue to a supervising faculty member's department can be substantial and provide compensation for faculty effort.
Measuring Outcomes of the Scholarly Programs
Given the resources committed to the research and scholarship programs at Duke and Stanford, evaluating their effectiveness in achieving the mission of promoting a critical, investigative approach to scientific inquiry is essential. In addition to surveying students about their perceptions of and satisfaction with the program, both Duke and Stanford assess the impact of the research experience on students' intentions to pursue a career in academic medicine. Both schools survey students longitudinally, distributing questionnaires at the end of their third year, upon graduation, and in their first postgraduate year. Moreover, the number and quality of peer-reviewed publications produced during medical school also provide an objective measure of success.
Duke University SOM
Duke performs serial evaluations of the third-year program, surveying students after their third year, upon graduation, and at the end of their first postgraduate year. To reduce bias by ensuring adequate response rates, survey completion prior to graduation is mandatory. In general, students consistently evaluate the third year favorably. For example, results of a survey administered to the class of 2009 indicated that 95% of the students rated their third-year experience positively; approximately half rated the research experience as “excellent,” (n = 49/102), while slightly less (46/102) rated it as “very good/good.” These responses are consistent with those of prior graduating classes.
Although the students receive the third year favorably, the long-term impact of this experience in influencing students' academic career trajectories and their leadership positions, and in imparting the scientific skills needed for good clinical practice, is more difficult to gauge. Although long-term data regarding the number of students ultimately pursing academic careers are not yet available, a mandatory questionnaire administered to the class of 2010 revealed that a higher proportion of students reported that they were interested in an academic career after their research experience (81%; 79/98) than they had been before their third year (71%; 70/98). In this same class, 87% (85/98) of students felt that the research experience at Duke influenced their future career plans. Although this percentage is only a surrogate for the number of students who eventually pursue academic careers, it is consistent with previously published studies that found that a dedicated research experience during medical school influences academic career choices.6,7 Ultimately, defining the durable impact of Duke's dedicated research experience in influencing academic career choices may prove difficult, and future studies must examine the effect of the dedicated research experience on Duke graduates' academic choices compared with the choices of graduates of comparable research-based institutions. Thus, an additional goal of the third-year program is to survey early-career and midcareer alumni of the third-year experience at Duke to assess whether the scholarly program has had a durable impact on shaping their careers.
Another objective measure of the success of the research experience is the number of peer-reviewed manuscripts that Duke students produce. As noted above, nearly two thirds of Duke graduates publish at least one scholarly, peer-reviewed article during medical school,3 although these are not required by the third-year program. To encourage students to practice scientific writing, Duke faculty made the decision to allow a submitted scholarly manuscript to serve as a thesis alternative. Because of the compressed research time frame, only a minority of students have a manuscript published or in press by the end of their third year, although a much greater proportion have manuscripts under review or in preparation. This is reflected by a recent survey of the class of 2010, which revealed that 28% (22/79) of students reported having had a manuscript accepted for publication during their third year and 92% (80/87) reported that they were preparing one or had one under review.
Stanford University SOM
Student surveys have suggested that the research experience during medical school at Stanford has influenced students' career choices, enthusiasm for research, and commitment to academic medicine. Jacobs and Cross8 reported in 1995 that 90% of Stanford students responding to a questionnaire had engaged in research during medical school, 75% had published at least one manuscript, and 52% had presented at a national meeting. Importantly, three quarters of students responded that the experience motivated them to pursue further research, and 60% indicated that they planned a full-time academic career. (The questionnaire also explored the attitude of faculty and teaching staff who had worked with students, and nearly all found their involvement rewarding and perceived that the students had had a valuable experience.8) This experience is consistent with the report of O'Sullivan and colleagues9 that demonstrated, on the basis of interviews with students and residents from another institution, that early exposure to research has a positive effect on attitudes about careers in academic medicine.
The long-term impact of Stanford's newly required scholarly concentration program is not yet fully known. The expectation is that students will be more likely to incorporate a critical, investigative approach in their future work if, at an important juncture in their development, they undertake a robust research experience. One outcome that Stanford will follow is the percentage of SOM graduates who enter careers in academic medicine. An equally valuable outcome is the percentage of graduates who do not enter academic medicine yet use a critical approach—such as scientifically appraising literature and practice guidelines—to challenge dogma and better safeguard their patients' health during their careers in medical practice. This latter outcome may be difficult to determine but is a highly desirable effect of the program.
Future Challenges for Medical Student Research and Scholarship
Although the research programs at Duke and Stanford are long-standing components of each school's curricula, the programs do face challenges resulting from increasing national demands on medical education and from the inherent complexities of research. Each school has attempted to maintain the rigors of medical training, and each has rejected the notion that the addition of a research requirement might dilute or compromise the core medical education. Both schools have gained time for student research by eliminating redundancies and increasing efficiencies through course integration. At Duke the research time has been partitioned to the third year of medical school, while at Stanford some research occurs throughout medical school; each of these arrangements has created scheduling challenges and the need for greater flexibility to accommodate student and programmatic needs. The financing of dedicated student research is an ongoing issue and is a prominent future challenge. Each school has used NIH or endowment funding (and other creative means) to subsidize research so that medical students do not graduate with greater indebtedness. Adequate funding for faculty support must also be ensured for these programs to remain viable in the future.
Duke University SOM
Although students consistently rate the third-year research experience at Duke as a positive component of their medical school education, a number of significant challenges remain. One of the difficulties in initiating a dedicated research experience is the reduced contact time students have with basic science faculty compared with students participating in a more traditional curriculum. At Duke University, the major trade-off for the third-year scholarly experience is the compression of the basic science curriculum into a single year. Several modifications enabled streamlining the basic sciences into just the first year. In 2004, Duke faculty developed a new curricular model, called Foundation for Excellence.3 At that time, course directors refashioned the 11 courses previously taught in the first year to the following four integrated courses that flow from the cellular and subcellular bases of normal anatomy and physiology, to systemic pathological processes and organ-specific pathology, and to therapeutic interventions: (1) Molecules and Cells, (2) Normal Body, (3) Brain and Behavior, and (4) Body and Disease. The integration allows students to more efficiently integrate basic science principles in a multidisciplinary context.
Clearly, the success of the research year is contingent on a medical student class that is both motivated and capable of taking advantage of the opportunities that the program offers. Admitting such a class can be challenging, as the student characteristics necessary for a successful research experience may differ from those necessary for attaining success in more traditional classroom and clerkship experiences. Thus, members of the Third Year Committee should actively engage with the admissions process, and admissions personnel must prioritize the qualities predictive of success for the third year, such as personal and professional maturity and commitment to research and leadership, along with more traditional predictors of academic success.
Another challenge for Duke's third-year program is thoughtfully integrating it into the overall medical school curriculum. The third year is qualitatively different from the standard didactic and clerkship experiences of the first two years, and, given the level of intensity and commitment associated with the initial portion of Duke's compressed medical school curriculum, it is not uncommon for students to delay decisions related to the third-year program. This lack of planning may prevent students from taking full advantage of the inherent flexibility of the third year and may result in a suboptimal research experience. To begin the process of preparing for the third year early in medical school training is important. Study program directors need to play a central role in this early stage of planning, as they are best qualified to describe the breadth of clinical and basic research experiences in their study program and to advocate student needs in identifying a compatible mentor.
The highly individualized nature of the third-year experience also makes meaningful and consistent student assessment difficult. Traditionally, students' scholarly research work was graded on an honors/pass/fail basis. The lack of objective data necessary to judge student performance and the large number of mentors, each of whom worked with a maximum of two students, led to an inflated number of honors grades. This grading system did little to discriminate true differences in student performance, so students now receive only pass/fail grades. However, students also receive a separate grade for the thesis or thesis-equivalent. Multiple members of the Third Year Committee review each student's project. In addition to providing comments and feedback for the students, each of the reviewers assigns an NIH-style score to the final written product. Top submissions are eligible for honors, and this designation appears on the student transcript. Additionally, the Alpha Omega Alpha Committee, in conjunction with a subcommittee of the Third Year Committee, grants special recognition to the students who produced the most outstanding laboratory-based and the most outstanding patient-oriented research theses and presentations.
Stanford University SOM
Students and faculty have shown great enthusiasm for the scholarly concentration program at Stanford during its first five years. However, issues remain that challenge the program's sustainability. To make room for the program in the student schedule by creating additional elective time, in 2003 SOM curricula planners reduced basic science instruction in the curriculum by approximately 30% in years 1 and 2. The SOM achieved this time savings by building more efficient, integrated, multidisciplinary courses based on organ systems rather than on individual disciplines. Although faculty initially resisted reducing basic science instruction hours, they seem to have accepted the new time allocation. However, if student acquisition of basic science knowledge were to decrease—for instance, if Step 1 scores were to decline substantially—a backlash among faculty and a call for restoring the former time allocation would likely occur.
Financing the scholarly concentration program remains an important issue. The Medical Scholars Endowment provides a large portion of the funding for faculty time, administrative support, and medical student research. If the value of this endowment were to decrease (a real concern in the turbulent financial climate of 2008 and 2009), less funding would be available to support these key activities.
An important concern voiced by some faculty and regulatory oversight groups is the potential distraction that the scholarly concentration program, because of its temporal competition with the core curriculum, creates for some students. The underlying premise of the scholarly concentration program is that students will benefit by gaining expertise in an area of passionate interest and that their zeal for scholarship will carry over to the study of medicine in general. The other premise is that students will be capable of simultaneously engaging in rigorous medical studies while pursuing a concentration. Both of these premises seem valid as illustrated by the success of the vast majority of Stanford students. However, occasionally students have been so engaged by work in their concentration that their performance in the core curriculum has suffered. Conversely, other students have focused heavily on required core course work—either because they enjoy it or struggle with it—to the extent that the concentration has received insufficient attention. For both of these types of students, a common remedy is to expand the student schedule to include a fifth year of medical school, which in almost all cases permits sufficient time to master the core curriculum and make progress in the scholarly concentration.
At the initial introduction of the scholarly concentration program, the Stanford faculty was concerned that the program might compete for student attention with the core basic sciences and decrease student mastery of this important knowledge. To address this concern, the Stanford SOM compared students' scores on USMLE Step 1 from 2001 to 2004 (the last cohorts of students from the prior curriculum) with scores from 2005 to 2007 (the first cohorts from the new curriculum with required scholarly concentrations). The mean USMLE Step 1 score from students in 2001 to 2004 was 230, and scores for students from 2005 to 2007 increased to 237 (mean difference, +7; 95% confidence interval, +1.7 to +12.3; P = .01, unpaired Student's t test). Although many factors contribute to the USMLE results, and these results are from different cohorts of students, there is certainly no evidence of an adverse effect on USMLE scores associated with the introduction of the required scholarly concentrations.
Lessons Learned
The third year at Duke and the scholarly concentration program at Stanford have both undergone changes over the past decades to stay current with trends in medical education and to remain valuable elements of each school's medical curriculum. Third-year and scholarly concentration administrators have learned several key lessons during this evolution. First, faculty must support the concept of a mandatory research requirement. At both schools, the basic science faculty gave up some traditional classroom time to support dedicated time for research scholarship. At both schools, time lost was “recovered” by attempts to be more efficient with allotted instructional time, such as by achieving greater course integration. These curricular adaptations required faculty sacrifice and cooperation. In addition, both schools rely heavily on program directors and individual mentors to provide countless hours working with students before, during, and at the conclusion of the research project. Other programs, such as the Clinical Research Training Program at Duke and the Stanford Institutes, have welcomed medical students and provided them with additional resources and experiences. The commitment of these additional faculty provides further evidence of the ongoing commitment of faculty to support mandatory student research. Second, a system of careful oversight for the research program must be in place to ensure that each student has a valuable experience. Although not all research projects are successful in terms of producing new discoveries or publishable results, appropriate oversight ensures that each student enters an environment that maximizes the potential for success. Third, and perhaps most important, is the need for the research programs to maintain both flexibility and a diversified menu of options. Originally designed as a laboratory-based research opportunity, Duke students now have a wide range of experiences available to them. Similarly, the scholarly concentration program at Stanford attempts to accommodate the interests of an increasingly diverse student body. The opportunities that both programs now offer reflect the different backgrounds that students bring with them to medical school and the rapidly changing needs of future leaders of medicine.
In Sum
Although the student research programs at Duke University SOM and Stanford University SOM differ, they share many features and objectives. The programs share the vision that a period of dedicated research provides a valuable experience for a medical student, whether the student aims to be a community-based clinician or a funded investigator–scientist at a research university. Both schools have learned that support of and involvement by faculty, preferably in a close mentoring role, are needed to ensure a successful student research experience. Both schools have learned that the programs need to be well funded and offer diverse courses of study, ranging from bench work to clinical work to community-based service learning, to appeal to increasingly diverse student bodies.
The third-year research requirement has been an important part of the Duke curriculum for more than 40 years. Although not the oldest program in the country (Yale has had a thesis requirement as part of its undergraduate medical education program since 1839), it serves as the foundation of Duke's medical school curriculum. When Duke underwent curricular reform in the late 1990s, the perceived value of the third-year experience was such that it was the one year left largely intact, with all other changes working around the research year.3
At Stanford, research has also been an integral part of the educational experience for nearly 50 years. The approach at Stanford has been flexible; students are allowed to conduct research either during a dedicated year (as at Duke), or (as they do more commonly) during a longitudinal experience spanning several years. In Stanford's most recent curriculum reform (2003), the research commitment was formalized by requiring that each student participate in the scholarly concentration program, which has become the centerpiece of the new curriculum.
The programs at Duke and Stanford continue to evolve as student and faculty interests change. Early data, obtained through student surveys and preliminary assessment of student scholarship, suggest that the programs are successful in interesting students in careers in academic medicine, although well-controlled outcome data are not yet available. Longitudinal studies examining the value of these dedicated research experiences will help establish the long-term benefit of these programs to the training of future physicians.
Acknowledgments:
The authors extend their thanks at Duke to Sherry Burton, administrative coordinator at the Duke University Third Year program, and Deborah Engle, research analyst for the Office of Curriculum, for their invaluable assistance collecting the data that were incorporated into this manuscript. This manuscript would not have been possible without the generous assistance of Mara Violanti, the Scholarly Concentrations Program administrator at Stanford University, who maintains all student records and data about the the program.
Funding/Support:
None.
Other disclosures:
None.
Ethical approval:
The student information provided in this report was obtained as part of Stanford's routine medical education practices; it is covered by a standard-practices protocol approved by Stanford University's human subjects committee. The study through which Duke data were gathered was approved by the Duke University institutional review board.
