In medicine, the worth of medical students and residents is too often defined by their number of research publications.
Research is a well-recognized way for medical students to distinguish themselves when applying for prestigious residency positions. A recent opinion piece published in the British Medical Journal remarks that research has become a “shortsighted, insincere effort,” with students seeing it as no more than a way to generate another line on their CV.
The expectation of research continues into residency. Research is a requirement for residents in many Canadian post graduate training programs, including family medicine, internal medicine,psychiatry, general surgery, and obstetrics and gynecology.
Yet despite this emphasis on research during training, the average practicing Canadian physician spends less than three percent of her work week on research, according to the National Physician Survey.
This unrelenting pressure to conduct research can cause distress to students, and the time consuming nature of research may also dissuade them from pursuing other important professional interests.
Some medical trainees have a strong enthusiasm for research, and devote large portions of their time to the pursuit of scientific discovery. They seek the intellectual stimulation research provides, are eager to solve unanswered clinical questions through research, and thrive with the mentorship and networking opportunities research offers.
But some trainees are more interested in medical education, global health, health economics and policy, or quality improvement. Although these non-research interests are recognized by the Royal College of Physicians and Surgeons of Canada, the immense pressure to conduct research can propel some trainees to set their true professional interests aside. They begrudgingly participate in research just so they can fulfill residency program requirements or maintain competitiveness for residency, fellowship, or staff positions.
This not only creates unenthusiastic researchers, it leaves little room for trainees to develop those other interests. Alternatively, some trainees feel pressured to turn endeavors that are not traditionally within the research realm into scholarly publications, because academia’s doctrine of “publish or perish” has, unfortunately, also become the norm in medical training.
It’s time for these issues to be recognized and addressed.
We need to reduce the pressure on medical trainees to exclusively conduct research. Medical schools and residency programs should encourage trainees to excel in any domain they are passionate about. The pursuit of these other passions may change how future generations of doctors are educated, lead to improvements in care in low-resource settings, deliver measurable and continuous improvement to patients at the frontlines or improve how healthcare policy decisions are made.
This perspective has been adopted at the University of Toronto’s Department of Medicine, which trains internal medicine residents. The guiding principle has now become that all internal medicine residents must engage in “the generation and translation of new knowledge to impact health,” instead of focusing solely on research.
There should also be a shared responsibility between the programs and the students as Canadian universities vary in their institutional focus on research. Canadian medical programs that consider training academics one of their goals should make that clear to applicants to promote the best fit between the program and the applicant. Similarly, those who choose to train in more academically oriented programs should embrace the scholarly opportunities offered at these sites.
At the same time, a national Canadian survey found that trainees pursuing research report barriers that limit their full potential. These include lack of funding, shortage of research mentors, research time competing with other responsibilities, and the lengthy and confusing research ethics process. These restrains prevent even the most motivated trainees from conducting high-quality research that will truly impact the field, because they are just unable to commit to more demanding and substantial projects. Providing protected research time in the curriculum, research mentorship opportunities, and streamlining the ethics approval process are all potential solutions institutions can adopt.
Without question, research innovation and discovery push evidence-based medicine forward. Still, some medical trainees have other passions that can result in equally valuable contributions to medicine. No matter what trainees wish to pursue, let’s give them the support they need to excel.
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Let’s call a spade a spade people, medical University doesn’t give a hoot about the research – it gives a hoot about the Big Grant and the potential to monetize. So we generate tons of MDs whose education time is devolved into poor-quality research while clinical learning suffers, leading to poor clinical care, while the dedicated researchers are hindered by having to babysit med students who don’t give a damn in the lab.
Some of the most “respected” surgical chairmen in Canada today provide no clinical care at all! Don’t tell me that the top-down disdain for point-of-care training doesn’t filter through.
Medical school should teach medicine first and last. Let those of us MDs who are inclined to research take time from practice down the line to hone our research skills at the same time we are practicing and so learning to appreciate where the research should best be directed.
Research Exposure Should Remain Part of Residency Training
To respond to this viewpoint we first wish to emphasize that, in our opinion, one should not consider all “medical trainees” in the same context. The training needs of the medical student vs general medicine resident vs subspecialty fellow are very different. In this opinion piece, we address the training of the resident and subspecialty fellow.
Research exposure and training does not mean a resident is committing to a research career anymore than rotations through Gastroenterology or Cardiology means a medicine resident will ultimately practice in those subspecialties. While a research block can “jumpstart” additional post-MD training in a formal research fellowship or graduate degree for some, for others it should not be assumed that this is the goal. Research training is intended to expose the resident or fellow to a well- conceived research question, that is answered by a methodologically sound project that draws a conclusion. It is intended to provide an experience and an appreciation of the process of research.
Why is this important? It is important because, by its very nature, medicine is inextricably linked to research. As MDs we ask how to make the sick better, how to maintain peoples’ health, and by extension, the health of society. To answer questions about health and disease, over the years our research foci branched off from the classic and essential basic sciences, to embrace others such as epidemiology, translational research, research in QI and education, and expanded to use other methodologies not traditionally employed in “medical’ research, such as qualitative methodologies fine-tuned by the social sciences. Research is essential for health to move forward; without research and the generation of new knowledge the efforts to improve health will eventually stall, as there will be nothing new to bring to the table. MDs being trained in top academic centres should have an appreciation of the research process, even if they later choose not to partake in the generation of new knowledge themselves.
There is also a pragmatic reason to understand research and the process of doing it; patients expect it. With social media and the internet we know that many patients obtain information on health and disease from unreliable and incorrect sources. In order to have intelligent discussions with patients about new health claims, discoveries and knowledge, it is essential for MDs to understand sound research methodologies, analyses and implementation. To those who suggest that research can be taught in methodology and statistics courses, journal clubs with critical appraisal etc, we respond that this approach is akin to assuming one can practice any of the medical subspecialties by reading about them. The process of research is the generation of new knowledge through hypothesis development, testing and evaluation – and one must practice the process to best learn and appreciate it.
We hear the residents’ concerns and acknowledge that indeed research electives can run poorly with no skills acquired and nothing to show for it in the end. From our experience this problem usually occurs due to poor research supervision rather than an inherent problem with the notion of performing research per se. If the Department of Medicine is to promote resident-led research projects, then its various divisions are obligated to ensure that supervisors who take on residents provide well-designed projects, with close supervision and mentoring. There should be regularly scheduled meetings and the supervisor should also be readily available to the resident in between so that the project can be redefined or changed if roadblocks are met. In our view, improved faculty engagement and commitment to the research project and interactions with the trainees will yield better experiences and outputs for all concerned.
In summary, we believe the resident research block remains an essential part of training, but the perception of what research is and what the research block is intended to deliver, should be corrected. Resident research training is not undertaken to ensure a publication, or a presentation listed on a CV that may help get the resident a job. Research training involves being steeped in the culture of research to begin to learn how to ask a question to generate new knowledge, and to study how that knowledge can then be applied to better the health of your patient. Today at the University of Toronto medical research ranges from molecular studies of disease pathology to qualitative research aimed at policy development and education. With the vast range of opportunities and the world-class scientists available in the Department of Medicine, University of Toronto, there is something of interest for everyone.
The Division of Respirology Research Advisory Committee, Department of Medicine, University of Toronto
Jane Batt MD PhD, Chung-Wai Chow MD PhD, Marie Faughnan MD MSc, Andrea Gershon MD MSc,
Shiphra Ginsburg MD PhD, Margaret Herridge MSc MD MPH, Richard Horner PhD.
Dear All:
This is a superb piece that articulates exceedingly well the very reason why we instituted the resident research rotation in respirology in the first place. I commend you for this very thoughtful and well-written piece.
Doug
Thank you to the Division of Respirology Research Advisory Committee for sharing your thoughts on our opinion piece.
Our article discussed pressures and challenges faced by trainees when performing research. We agree that research is essential in moving the field of medicine forward and believe that trainees should all be exposed in some capacity to research. We realize that there is a lack of consensus regarding the objectives of a research exposure during training; What is the goal? If it is to learn how to develop a question/hypothesis? to learn about research ethics/integrity? to learn about basic principles of critical appraisal? Furthermore, the definition of “research” is unclear. Areas such as global outreach, education and quality improvement are not traditionally considered in the spectrum of research, but are starting to be recognized by some programs as “research”. We therefore need to first define the objectives of research in the medical curriculum, and then define what constitutes research. We could thus apply these defined overarching objectives to many different scenarios/settings encompassing research.
We applaud the internal medicine residency program for providing a research block for their trainees. The allocation of a research block during residency aligns with our views that trainees need additional support to conduct their research, such as having dedicated research time. We also applaud your emphasis of improved faculty engagement and commitment to trainee research projects. We agree that well-designed projects (projects that are feasible in a short time frame and that will produce an outcome of value to the career development of the trainee in addition to a meaningful research experience), close supervision, and mentoring will improve experiences for all concerned.
Trainees at top academic institutions have the invaluable opportunity of learning how to conduct research from world leaders in their field. It is therefore understandable that these academic institutions place a major focus on research, as they want to share these incredible resources with their trainees. We suggest that these institutions make these views clear to trainees during their CaRMS application process, so that the residency goals align with the candidates’ passions. Furthermore, trainees selecting academic centers such as the University of Toronto to complete their training should do so knowing that it is one of the top research intensive university in the country and that there will be an expectation that trainees at least “taste test” research.
We thank you for your response and hope this dialogue will help improve research expectations for medical trainees.
I think that the premise of the argument is fundamentally flawed in that it altogether separates research from other endeavors, such as public health, global health, education, and policy work when in fact research is an important aspect of all of these activities. Student may not be interested in “bench science” and that is completely acceptable. If all of us LOVED bench science we probably would not be aspiring physicians. Research takes many forms and I think that the authors purposely ignore this. The authors say “the pursuit of these other passions may change how future generations of doctors are educated, lead to improvements in care in low-resource settings, deliver measurable and continuous improvement to patients at the front lines or improve how healthcare policy decisions are made,” but they seem to omit the fact that progress in any of these fields is in fact research that typically is published and peer reviewed in some way, shape or form. The authors also make that argument that since research takes up only 3% of the practicing physicians time, that we should have place less emphasis on the importance of it. This again, I feel is fundamental flawed. ALL the major advances in healthcare practice and delivery is underpinned by research. Considering the major advances that have been made in the last 50 years, imagine what your practice and patient population would look like if we collectively doubled our research efforts. What if we spent 6% of our time doing research? How about 10%? Teaching without direct patient interaction takes up only 3% of the average physicians time, does that mean it is not a valuable pursuit either, or is it of fundamental importance to the progression of medicine? It’s also interesting that the authors left out the fact that the “other pursuits” that research takes students away from only occupy ~1.5% of the physicians time. By the authors logic it would see that we should spend less time trying to pursue these efforts during our medical training.
While I have spoken to many who agree with what you are commenting on, it is ironic and worth mentioning that This piece started out to be very interesting and then it started to dwindle really fast. Your commentary lacks actual and factual data. If you were to make any real comments about this matter, just a few comments from a few jaded residents cant be the basis for your paper above. You need to run surveys and ask what the reasoning of why they dont like research is etc. It could be because of the topic, because they lack actual training, etc. Once you have collected this information and only then, can you make an informed commentary such as this.
That being said, I cannot say that I have not heard such comments. I am a resident and I love research. I was saddened that while I attended the University of Toronto as a medical student that I saw some of the things you mentioned. The root of it was that for the UME the point was to have the check mark of saying that its students are doing research. However, the quality and the interests of the students were not factored into this matter. However, I can assure you that with 10 years of research experience and many publications it did not help me “pad” my resume for residency positions. Most residencies nowadays don’t care any longer about the lines on the CV with publications because many students have learned how to gain that on their CVs before even entering into medical school. As a person who evaluated the applications, I was surprised when I saw how everyone had many publications. When everyone has it … its not that impressive any longer.
Your comments above are a great start to a conversation, but you need to add more hard evidence into this if you want the conversation to turn into a debate.
Great article and viewpoint. I just wanted to point out that the areas characterized as not being research based “medical education, global health, health economics and policy” – can actually be approached in many different ways, including research. There are entire research degrees based on global health research etc. at many universities, and the contribution of research to these areas should not be overlooked.
Thanks very much for sharing your thoughts. I agree with you and Dr. Oyetunji’s point above that research can and should be done in areas such as medical education and global health, as the saying goes “you can’t improve what you don’t measure”.
I do think there are some of us that prefer to execute rather than evaluate. To have medical education research, there needs to be teachers who are willing to deliver a lecture. To have global health research, there needs to be physicians who are willing to work internationally. I think we should celebrate the contributions of these individuals as well. Even if their actions do not advance knowledge and generate new conclusions like researchers do, their dedication to their field of work is equally admirable.
Great article and viewpoint. I just wanted to point out that the areas characterized as not being research based “medical education, global health, health economics and policy” – can actually be approached in many different ways, including research. There are entire research degrees based on global health research etc. at many universities, and I think the contribution of research to these areas should not be overlooked.
Great article and an important attempt at changing the paradigm. At the Memorial University of Newfoundland, Faculty of Medicine we have been also making slow changes in this direction. I’ll give two examples. First, our medical students with passion for scholarship in education are encouraged to publish short technical reports describing “learning objects” that can be used for teaching and learning. These reports need to meet the four criteria of scholarship: build on prior knowledge, add new knowledge, be published and peer-reviewed (http://www.cureus.com/channels/simulation-archives). We have established Cureus Archives of Scholarship in Simulation and Educational Techniques, which is an on-line journal, which not only provides a portal for dissemination of scholarship, but also, as recently articulated by one group of the students: “…enables application of the CanMEDS roles in ways not traditionally taught in the classroom” (Alani et al (2016). Cureus 8(7): e685. doi:10.7759/cureus.685).
Second, another group of students focussed their efforts on establishing MUN MED 3D, which is the first Biomedical 3D Printing Lab and Innovation Centre in Newfoundland and Labrador entirely led by two medical students with the support from the Teaching and Learning Fund (http://www.med.mun.ca/Biomedical-Engineering/MUN-MED-3D/Team.aspx). The students designed MUN Med 3D to support educational needs of medical students, residents, as well as practicing health professionals, provide collaborative research and scholarship opportunities with other faculties within Memorial University of Newfoundland. They have also recognized a market opportunity to use 3D printing technologies as a means to provide innovative solutions to rural, patient centred healthcare needs, and develop experiential learning technologies in provincial, Atlantic Canadian and global contexts. Within a year, MUN MED 3D supported over 30 projects.
In summary, in the era of innovation and rapid implementation, and blurring the boundaries between arts and science, the departure from the traditional image of a doctor learning over a beaker is to be expected. As such, medical education should also incorporate scholarship and peer-reviewed dissemination of all innovation.
I am an academic surgeon with interest in global surgery and quality improvement. It’s interesting that you mentioned global health and quality improvement as some areas residents are interested in outside research. Your definition of research is what I will suggest you probably rethink. It’s difficult to improve what you don’t measure. How do you know you are getting from point A to point B? To me, again my bias, research is exciting. It’s the act of discovery and questioning the status quo. I believe everyone in healthcare should have some basic understanding of research as it makes you a better clinician, sifting through the evidence to know what is applicable to your patient or not. While journal clubs may help you understand how to review a paper, the act of contributing to the medical knowledge should not be left to a few. Obviously, you agree with this since you mention “the generation and translation of new knowledge to impact health,” as the focus of the department. That to me, is exactly what research is and you are already doing that! However, if you plan to measure and share that new knowledge and compare with existing knowledge, then learning how to do it right is critical. I don’t suggest forcing anyone to do research either, but I believe when done right, the results can be appreciated, even if that career path is not ultimately pursued by the medical student or resident. Hopefully you come across a researcher who will truly share the true definition of research. It’s definitely way more than what you think.
I think some involvement in scholarly activity is important to understand the evidence behind our clinical practice. This doesn’t get accomplished by simply participating in journal club. Often journal clubs focus on the flaws, and doing the research yourself teaches you how difficult collecting primary data is. Trainees should be allowed to declare their interest without judgement and amount of research they do in residency should be consistent with their career goals. Our goal as faculty should be to ensure that every trainee has a a positive research experience
Thank you for your insight Dr. Tangri. I am very fortunate to have met many inspiring mentors who supported me in all my scholarly pursuits, whether they are conventionally considered research or not.
I strongly disagree with the tone of this article. I am a resident research director.. without a basic knowledge of research methodology and skills to critically appraise literature .. the ability to care for patients with an up to date evidence based practice is challenging.. which I advocate we should all do in 100% of our practice. If you cannot appreciate the complexity of research & critically appraise medical literature .. you will become a technicians.. following unquestioning practice guidelines.
To “create researchers” by exposing them to it during medical school/ residency is not the general goal. Research is not just clinical trials. There are many forms of scholarly activity that can satisfy program requirements to help trainees to gain these insights. Additionally.. at least at Dal in my program … we in fact encourage scholarly activities within the “students passion”.. whether it is in education, global health, leadership advocacy etc. You can evaluate an educational program, create a policy or curriculum etc. Document it.. the background, unmet needs, process, implement, impact= Research project
Hello Dr. McKeen, thank you very much for reading our article and sharing your thoughts. I really appreciate your unique perspective as a resident research director. I wholeheartedly agree that the ability to critically appraise medical literature is an essential skill every medical student and resident should learn. Do you think this can be accomplished without active involvement in research projects, but through activities like journal clubs which are less time intensive and can expose students to a more broad range of literature instead of the few projects they are able to actively work on? Or do you think student involvement in research is essential in order to cultivate a true appreciation of research and understand its complexity?
Dolores, I agree with your statement : “Research is not just clinical trials. There are many forms of scholarly activity that can satisfy program requirements to help trainees to gain these insights.”
And agree that the training in critically appraising the work done in the health care discipline is a crucial requirement for avoiding mediocrity. The culture of being too busy to get passionate about all program requirements within the academic setting reinforces the culture of box checking. The extensive training these students receive must also allow a certain trust building then facilitating excellence within a chosen inquiry process.
My residency at U of T Ophthalmology included a research project that took up over half of my time in my first year of residency. I believe that it took me ten years of clinical practice experience to make up for that lost time.
In my final year of residency I saw an interesting dry eye patient associated with Crohn’s disease. My good friend was a GI resident who had the same patient. We worked together to publish a paper because we wanted to. There was no oversight by either of our staff men. We did it because we wanted to.
Forcing medical students to pad their CVs by taking part in scutmonkey research projects interrupts their educations.
I had thought that research was about asking questions to help answer the grey areas. You can’t know where the grey areas are until you’re well-versed in the field.
You can’t get well-versed in the field, let alone in anything, without years of study and practice.
Thanks for this article.
Bravo! Nice to see that the authors have put this issue up for discussion; I applaud them. And yes, I am an academic physician and a former IM Program Director, who has done “research” throughout my career.
I have often thought that this pressure to push trainees into medical research somehow devalues those whose passion and interests lay in the provision of excellent clinical care or medical education. I think if you look at the role models that most influenced physicians during their training, it was the exemplary clinicians and teachers and not necessarily the researchers. Since academic institutions, with their focus on research grants and the “publish or perish” paradigm, are where most physicians are trained, it is not surprising that there is an undue emphasis on mandated research in PGME, often to the benefit of faculty who have a readily available work force to move their research work forward. With PGME now extending outward into the community, this is a good time to debate the issue of requiring research during residency.
Thanks again for putting this up for debate.
“But some trainees are more interested in medical education, global health, health economics and policy, or quality improvement.”, all of these topics are worthwhile pursuits that raise stimulating questions. It is perhaps the definition of “research” as applied to medical student endeavours that is too narrowly interpreted. Finding a question that interests a student and engaging in the process of answering it whilst building a relationship with a supportive mentor should be inspirational, or at least a useful learning experience. Without the attempt to formulate a question and seeking to answer it, reading research is the Oslerian equivalent of maps, whereas the experience of going to sea is formative.
Thank you for sharing Dr. Adisesh. Perhaps broadening what “research” means is what we need to open doors for more students to pursue diverse experiences. Thank you also for the maps and sea analogy – personally I have always found experiential learning to be more memorable, engaging, and rewarding.
I have a PhD and am a former academic scientist. I knew many medical students who cycled through the labs where i worked who clearly had no interest in research and were only doing it to check a box. But I knew other medical students who loved research and in fact most of my academic mentors were excellent clinician-scientists. So it can be done well by those that love research. However, from a PhD point of view, the over-emphasis on medical student research by medical departments has another effect – unintentionally can de-emphasize the research being done by actual PhD and MSc students. For example, when i was a student, medical students were paid more than PhD students for the same work, with the justification that medical students need motivation to do research! If a medical student is interested in a career that focuses on research, they should be given that opportunity but if not, leave those lab spaces open for someone else who loves research.
Carol Watson, thank you for your response and pointing out that scientific research spaces should be reserved for those willing and able to do quality work and pursue questions with passion and creative intrigue. Requiring insincere research to check a box devalues the richness of our curiosities and dilutes opportunity for those who have an altitude and interest in scientific inqury and ultimately cheapens the product. Encouraging passion and excellence in all that is health care should be the goal for trainees and practitioners in this and other sectors or our society.
Thank you both for your thoughtful comments and pointing out an important impact we did not consider while writing this article. “Encouraging passion and excellence in all that is health care should be the goal for trainees and practitioners in this and other sectors of our society.” – Well said.
Give me a break. Once sat in talk from Gillian Hawker who quite frankly dismissed a trainee’s clinical expertise/interest as irrelevant in the eyes of the Department of Medicine. This resident pursued a specialized clinical training program with formal recognition from the Royal College of Physicians and Surgeons of Canada, which undoubtedly would help with local “translation of new knowledge to impact health”. When talking about the required–and in the eyes of many residents, seemingly arbitrary–credentials it takes to achieve an appointment in Toronto, if my memory serves me correctly, at one point she went so far as to say, “tough luck, if you don’t do it, someone else will”.
Actions speak louder than words.