Abstract
Background: Recruitment of medical graduates to research careers is declining. Expansion of medical knowledge necessitates all graduates be equipped to critically evaluate new information. To address these challenges, a mandatory intercalated degree programme was introduced as part of curriculum reform.
Aims: To review the place on intercalated degrees, the methods available for learning about research and to analyse experience with a new university programme focusing on research.
Methods: A literature review followed by the analysis of experience with eight cohorts of students who had completed the new programme.
Results: A total of 1599 students completed the programme. Laboratory-based research was the most common choice followed by clinical research, population health, epidemiology, medical humanities and mental health. Also, 93% of students spent over 75% of their time undertaking research. Sixty-three students published their research, half as first authors. Students and coordinators support the programme. Learning about research during the postgraduate phase is variable and frequently left to individual choice.
Conclusion: Intercalating an additional degree focusing on research can achieve a number of learning objectives but demands a level of maturity, autonomy and preparedness, not uniformly present in students undertaking a mandatory intercalated programme. A more realistic goal is the development of ‘research-mindedness’ amongst all students.
Introduction
Attention to the declining interest in biomedical research amongst medical students and graduates was first raised in 1979 (Wyngaarden Citation1979), when it was speculated that clinical investigators might become ‘an endangered species’. Others (Rosenberg Citation1999; Miller Citation2001) added similar concerns leading to the recognition that academic medicine was in crisis and required revitalisation and reinvention (Clark & Smith Citation2003). A campaign was launched to investigate and address this phenomenon (Clark & Smith Citation2003) and a number of radical changes proposed in academic medicine (Tugwell Citation2004).
Introducing future clinicians to biomedical research whilst they are still medical students is considered one way for them to learn about the importance of research and research methodology, whilst at the same time hopefully generating the interest of some in future academic careers (Evered et al. Citation1987; Faxton Citation2002). This opportunity can be provided by intercalating an additional degree within a primary medical degree programme where the focus is on learning about research methodology and the completion of a research project (Evered et al. Citation1987).
A new intercalated degree in medicine
A new undergraduate medical curriculum of 12 semesters (6 years) was introduced in 1999. A key feature has been a mandatory intercalated research year – Advanced Medical Science (AMS) Year – between semesters five and eight. Successful completion entitles students to graduate with a Bachelor of Medical Science along with their normal MBBS degree. The first cohort of new curriculum students commenced in 1999 and started their AMS year in 2001.
Eight learning objectives () have been developed for this programme. Students choose their research project from a wide list of available topics published annually on the university's website and negotiate directly with the host department or institution. This may be in one of the Faculty's departments or allied institutes or at other centres of excellence in Australia or overseas. The hosting department receives $5000 for accepting each student. All students must undertake a supervised research project preceded by standardised research methods training. The programme is made up of a minimum percentage of research/investigative work with the remainder – if applicable – being coursework. Those students who elect to undertake coursework as part of their AMS year must choose between three university coursework subjects, namely Intermediate Epidemiology and Biostatistics (for quantitative research), Qualitative Health Research (for qualitative research) and Advanced Techniques for Laboratory-Based Research. The key assessed component of AMS is a research report of approximately 10,000 words which is assessed by two examiners who are independent of each other and from the student's AMS ‘unit’. A third examiner is added if there is a significant discrepancy in the marking. If a student undertakes one of the didactic courses as part of their AMS year, they are formally assessed by examination in accordance with standard university assessment practice.
Table 1. Learning objectives for the AMS Year
Materials and methods
Analysis has been performed on the eight cohorts of students who have completed the AMS year since 2001. This includes location of research, the composition of each student's AMS programme, the broad areas in which research was undertaken and the correlation between each student's AMS score and their course aggregate score prior to their AMS year (Semesters 1–5). Students’ academic output in terms of publications and presentations and their perceptions of the programme obtained from a survey carried out on the 2001 cohort have been reviewed. Impressions of the coordinators of the AMS programme were obtained through a survey questionnaire sent to all (74) coordinators in 2006.
Results from analysis
A total of 1599 students have completed the programme () with the majority (88%) doing so in Australia – predominantly in their local State. The most popular overseas destinations were the UK, Singapore and the USA.
Table 2. Number and percentage of students in each cohort who completed the AMS programme in Australia or overseas
The percentage of research undertaken by each cohort is shown in , with the remainder being coursework. The proportion of research completed by individual students has increased each year with 81% now allocating 80% of their time to a formal research project and 55% allocating 100%.
Table 3. Number and percentage of each cohort who carried out different levels of research
The number and percentage of AMS students who engaged in different areas of research () has remained fairly constant over the 8 years. Laboratory-based (39%) was most common, closely followed by clinical research (35%) with the remainder or ‘others’ (6%) including population health, epidemiology, medical humanities and mental health.
Table 4. Numbers and percentages of AMS students in key areas of research
Final assessment results for the 2008 cohort were not available at the time of writing. Of the remaining seven cohorts or 1378 students, eight failed to meet the assessment requirements of the programme. Marks obtained by each student for their AMS were substantially higher than for their previous course aggregates (). Students with high course aggregates were very unlikely to perform poorly on AMS.
Figure 1. Relationship between final AMS score and Semesters 1–5 aggregate for all 1378 students in 2001–2007 cohorts. Correlation = 0.403.
A total of 63 peer-reviewed publications have been produced to date by the eight cohorts, with students listed as first authors in 36 papers. Sixty-three students – mostly the same students – delivered presentations at conferences. A number of students have been awarded prizes and awards.
One hundred and thirty students (75%) completed the survey questionnaire. Students were satisfied with their performance (Mean Likert rating 3.7) in the year as a whole and with the help they received from their supervisors (3.9). They credited the AMS experience as contributing to their personal (4.0), research (3.9) and professional (3.7) development. Fifty-five (42%) students did not have sufficient information to make an informed decision relating to their choice of research unit. Of the 107 free responses received, 46 (43%) were complimentary, eight thought the AMS should be optional, six were concerned about the marking arrangements for research projects and three were concerned by the length of time it took to obtain ethical consent for their projects.
Fifty (68%) of the 74 programme coordinators surveyed returned the completed questionnaire. Overall, comments were positive with the opportunity to have medical students involved in departmental projects regarded as valuable, enjoyable and worthwhile. Thirty-two respondents (64%) agreed that the AMS learning objectives were appropriate and 25 (50%) believed these were being achieved. Forty-five (90%) considered the supervision of AMS students in their area as complying with the university requirements, and eight commented on the burden of supervision. Twenty-nine (58%) considered ‘buddy projects’ a good idea as this would encourage teamwork, increase the scope of the project and student achievement and help in recruiting and retaining supervisors.
Discussion
This study has shown that the AMS programme is valued by students, who report that it contributes to their personal and professional development. Similarly, coordinators are supportive of the programme but highlight the burden it places on the hosting departments and the need for adequate resources to make it a success (McManus et al. Citation1999).
The majority of students choose to complete the AMS programme in their home State, most likely due to familiarity with local opportunities and departments and financial considerations. Those who have chosen to travel overseas gained from their exposure to new professional and cultural experiences. However casual overseas arrangements – often organised through a student's own or family contacts – can have accompanying educational risks and are no longer approved. In addition, there are professional and personal safety issues to be considered depending on the country being visited (Blundell et al. Citation2007).
An increasing number of students have chosen to focus entirely on research during the programme. This change may be attributed to genuine interest or to positive experiences by previous students, or the perception amongst the student culture of the importance of providing evidence of participation in research in their curriculum vitae.
Whilst laboratory and clinically-based research predominate, students do choose from a wide spectrum of other rewarding opportunities, which can expand what might otherwise be a narrow education. A range of subjects are now available to intercalating students including in the basic and clinical sciences, primary health care, public health, medical law and history of medicine (Blundell et al. Citation2007). It is important, particularly with mandatory intercalated programmes, to include subjects which cater for the broad spectrum of students involved and their different career aspirations.
Very few students failed the AMS programme although a number presented during this year with problems for the first time in their course. It is possible that the non-structured nature of the programme and the delays or difficulties in obtaining ethical consent for research projects have contributed to this. The time available to complete a research project is short and students are now provided with significant advice (Smajdor et al. Citation2009) and support in applying for ethical approval for research, this step being considered as a vital learning component of the AMS programme. AMS students require considerable supervision and benefit from experienced supervisors. When a supervisor is inexperienced, or the project is ill-conceived or the student lacks skills and/or motivation, problems can arise which may not be easily resolved.
A number of students have delivered presentations at conferences and published papers, some of whom are listed as first authors. The lag time to publication may have underestimated academic achievements by the eight cohorts. It should be noted that this desirable outcome may not be possible in some areas such as in social and humanities research where student's limited research competencies and the short time available allow for only small-scale and largely unpublishable projects.
Intercalated degrees and their timing
About one-third of UK medical students complete intercalated degrees, usually by adding 1 year to the basic 5-year undergraduate course (McManus et al. Citation1999). Depending on the school, this is either obligatory or accessible only to those students who have performed exceptionally well in the early years of the course. A small number of graduate entrants in Australia and the UK intercalate a degree in addition to the degree they obtained prior to entry to medical school. Intercalated degrees are predominantly at a Bachelors level although some students undertake a Masters. MB PhD programmes have expanded but are reserved for a few gifted students (Power et al. Citation2003).
One hundred and twenty-one medical schools in the US and 13 in Canada currently offer combined MD-PhD programmes (MD-PhD. Dual Degree Training Citation2009). Most of those in the US provide financial support for students whereas in the UK funding is limited particularly since the Medical Research Council removed its assistance.
The timing of intercalating a degree varies but usually takes place over a discrete period of the undergraduate medical course. It has been suggested that such a programme could run as a thread through the medical school curriculum and some of the new British medical schools planned to do so by placing training in research methods centre stage in their curriculum (Howe et al. Citation2004).
An intercalated year adds significantly to the length of the medical course. Student selectives can provide a brief opportunity with an established research team as a ‘taster’ but cannot be expected to result in the development of research related skills given their brevity.
Other ways of learning about research
Learning about research including its methodology is also possible during the postgraduate component of the learning continuum. This may be undertaken early after graduation occurs during the Academic Foundation Programme in the UK (Rough Guide to the Academic Foundation Programme Citation2009) or at a later stage. Individuals may voluntarily choose to undertake research at a Masters or Doctorate level, or complete a taught research appreciation course at a Masters level (Grant & Golombok Citation1995). On the other hand, a research project may be a compulsory requirement of the education and training programme of some specialties (Collins et al. Citation2007). The actual learning about research methodology which occurs in the latter may be very variable.
Purpose of undertaking an intercalated degree
The main purposes of intercalating a degree are said to be the development of research skills and an in-depth study in areas of particular interest over an extended period (Medical Research Council Citation1986). It has been stated previously that ‘intercalated awards were of the highest value in introducing future clinicians to research, and providing a cadre of graduates who were likely to become attracted to, and excel in, a career in academic medicine’ (General Medical Council Citation2001).
It is also considered beneficial for medical students to interact with a new and diverse peer group outside their medical school which might broaden their horizons and offer fresh perspectives on the learning process (Rushworth Citation2001). Too often, medical students can be isolated from the rest of the university campus and the main body of university students. A number of students leave the medical course prior to its completion for different reasons. For those who have satisfactorily completed three or more years, an exit qualification should be awarded as recognition of this period of academic endeavour and achievement.
The reasons why medical students choose to intercalate a degree are thought to be related to improving their long-term career prospects (Blundell et al. Citation2007; Cleland et al. Citation2009) as additional points are given by many selection panels for additional degrees (Cleland et al. Citation2009). The reasons for not intercalating (Blundell et al. Citation2007; Cleland et al. Citation2009) include the perception of the student body, such as lack of awareness or misunderstanding, financial considerations and time-costs or a lack of interest in undertaking research. Financial and time considerations are becoming more significant and are likely to be a greater deterrent for females (Andrew 2002). Students worry about falling behind their peers in the progress of their careers and the challenges posed on re-entering the medical programme after a period in full time research. These can be addressed by mechanisms to maintain clinical contact and knowledge and with help to ensure smooth transition back into the final clinical years (Power et al. Citation2003).
The evidence to support the academic benefits of intercalating a degree in medicine remains conflicting. A UK Committee of Vice-Chancellors and Principals (Citation1997) report into academic careers commented that the data did not clearly demonstrate intercalated degrees cause students to take up academic careers. They further stated ‘it may be that those that are interested in academic research are those that seek to do the intercalated degree’ (Committee of Vice-Chancellors and Principals Citation1997). A subsequent longitudinal study of British medical undergraduates (McManus et al. Citation1999) demonstrated that intercalated degrees resulted in greater interest in research careers and higher deep and strategic learning scores. The effects were reduced in those schools where it was mandatory or most students intercalate a degree.
There is some evidence that intercalating students are more likely to enter academic and research careers (Evered et al. Citation1987; Nguyen-Van-Tan et al. Citation2001) and that the type of department in which students undertake their research influences their subsequent choice of specialty (Nguyen-Van-Tan Citation2001). This is similar to the influential role played by a student's personal experience of a subject and of a supportive mentor during a clinical attachment on their ultimate career choice (Goldacre et al. Citation2004). A recent study on the career preferences of medical graduates (Goldacre et al. Citation2007) suggests non-graduate entrants who undertook intercalated degrees were more likely to opt for a career in hospital medical specialties.
While it is easy to debate the evidence for or against intercalated degrees or indeed any research experience, there is a crisis in academic medicine in its widest sense. The most recent data update on staffing levels in UK medical schools ‘indicate more acutely than ever the crisis of recruitment and retention in clinical academic medicine’ (Medical Schools Council Citation2008). This has occurred at a time when the need for experimental medicine followed by appropriately designed trials has never been greater (Morrison & Wood Citation2004) and when opportunities for physicians to engage in research are enormous (Byrne Citation2004). It is therefore vital to develop clinician–scientists who will ensure that scientific discovery ends at the bedside (Faxton Citation2002).
The opportunity provided by the AMS programme does enable students to undertake research and exposes them to the research environment. It is inevitable that a compulsory programme which demands a great deal of undergraduate students in terms of maturity and autonomy should produce the mixed results found from the surveys. There has perhaps been a lack of clarity from the beginning about what is meant by ‘research’ and what might be a realistic expectation of a research-based AMS year.
Regardless of how able they may be, AMS students are not equivalent in university training to BSc or BA students commencing their honours year. Moreover, honours students are not expected to learn and undertake research without a strong culture of coursework by seminars, research methodology training and laboratory or other research under close supervision. Previous training during a BA, for instance, is thought to have trained students how to find and use research literature, construct and organise notes and research results and write up their findings in a critical manner, skills which honours students start building on in their honours year. Research training is training by apprenticeship under supervision in a longer time framework.
Given the limited time and resources, it may be more worthwhile to install in medical students at a generic level ‘research-mindedness’ – the way of thinking as a researcher in all areas of medical work from laboratory, clinical, epidemiological to qualitative and medical humanities. This obviously links to evidence-based medicine but the goal should be to produce doctors who ask questions of themselves, of data, of other research, or clinical experiences and of problems, challenges and even failures. Research-mindedness also implies a habit of noticing patterns, anomalies, associations, deviations and then framing questions and synthesising current and new knowledge. This means acquiring some understanding of deductive and inductive reasoning which medical graduates might then take to the bedside and all aspects of clinical practice.
The Royal College of Physicians and Surgeons of Canada has identified (Frank Citation2005) ‘scholar’ as one of the seven important roles of a clinician and listed a number of key competencies which underpin this role including ‘physicians are able to critically evaluate information and its sources, and apply this appropriately to practice decisions’. The General Medical Council (2009) lists ‘the doctor as a scholar and a scientist’ as one of the three major outcomes for undergraduate medical education and describes four key competencies under the sub-heading ‘apply scientific method and approaches to medical research’.
Exposure to research or placing research methods centre stage in the curricula should commence during undergraduate medical education and continue throughout training (Morrison Citation2004). This should help to install a greater level of research-mindedness and provide graduates with the ability to update their skills so that they can become critical consumers of new information presented to them throughout their professional careers (The Commonwealth Fund Task Force on Academic Health Centres Citation2002). It should also aid in the more expeditious implementation of evidence-based new therapies. At the same time, it will help an important core to catch the vision of research and go on to become clinician-scientists so important to the future development of health care.
There is no conclusive evidence to suggest that the AMS programme has artificially selected a particular type of student to the course. The University of Melbourne will move to a new 4-year Doctor of Medicine (MD) professional entry masters level programme in 2011. Designed for those who have completed their undergraduate studies, it will deliver advanced clinical and academic training. The findings of the review presented in this article have been used to inform its structure and development. A programme to develop ‘research-mindedness’ is proposed which will focus on a 6-month scholarly elective in the fourth or final year of the programme. This will build on the strengths of the current AMS programme while acknowledging some of its weaknesses. In particular, it is planned to ‘cluster’ students and their projects into cohorts to facilitate a team approach to research and reflection.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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