The Importance of Engaging in Scientific Research during Medical Training

Abstract

Many components of required skills and competencies exist, and are felt to contribute to the successful completion of training for independent practice in the medical field as a physician. These requirements are documented and detailed in a temporal fashion during the training period and used for advancement during training as well as documentation of successful completion of that training. While clinical skill development that allows optimal care and treatment of patients is of utmost importance during this training, other components of the training are important and contribute to the ideal development of a well-rounded and credentialed physician. One of these other components which is very important and needs to be recognized is the engagement of medical trainees across disciplines in academic and research scholarly activity. This engagement is an important component of medical training, and the development of skills and didactics geared toward efficient and accurate performance of research is essential.

Medical education training starts in undergraduate college pre-medical courses, continues to medical school and internship, and then progresses to additional training thereafter in residency, fellowship, subspecialty fellowship and eventually continuing medical education to maintain certification. Many requirements during training are documented and detailed in a temporal fashion during the training period and are used for advancement as well as documentation of successful completion of the training. While clinical skill development that allows optimal care and treatment of patients is of utmost importance during medical training, other components of the training are important and contribute to the ideal development of a well-rounded and credentialed physician. One of these other components that is very important and needs to be recognized is the engagement of medical trainees across disciplines in academic and research scholarly activity. This engagement is an important component of medical training, and the development of skills and didactics geared toward efficient and accurate performance of research is essential. We review the importance and central benefits of engagement in research during medical training for the enrichment and development of the optimally credentialed physician.

The Importance of Research

The importance of research throughout all levels of medical training cannot be understated. At the undergraduate level, research provides an early exposure to the field of clinical medicine. Learning the fundamentals of research and biostatistics is the skill that is utilized for the rest of the trainees' career. Additionally, a strong research background strengthens a student's application to medical school. At the medical student level, research helps introduce students to evidence-based medicine. Participation in research, presenting posters, and publishing papers help bolster medical student residency applications and make them more competitive to program directors. Similarly, participation in research at the resident level makes the resident more appealing for fellowships and attending positions, especially in major academic centers. Once at the level of the attending, research can be tied to educational grants, academic promotions, and salary determination, further highlighting its importance at every stage of training. While we are using the term “research” in the overall general sense in our document, various forms of research may be undertaken spanning the gamut from basic science research to clinical translational research. Discussion of the types of research undertaken is beyond the scope of our document but should be recognized as an important consideration in the process.

Research Requirements during Training

The Accreditation Council for Graduate Medical Education (ACGME) describes medicine as both an art and a science. ACGME states that “the physician is a humanistic scientist who cares for patients. This requires the ability to think critically, evaluate the literature, appropriately assimilate new knowledge, and practice lifelong learning. ¹ ” The ACGME continues to say that residents should be proficient in the fundamentals of scientific inquiry. This entails being well versed in structure of a research project including “how research is designed, conducted, evaluated, explained to patients, and applied to patient care. ¹ ”

Effective as of July 2022, the ACGME has a list of specialty specific program requirements for research and scholarly activity.Effective as of July 2022, the ACGME has a list of specialty specific program requirements for research and scholarly activity. For example, in Internal Medicine, Cardiology, Gastroenterology and Endocrinology residents must participate in scholarship with at least 50% of a program's residents participating in scholarly activity such as grand rounds, posters, publications, etc. In cardiology, the American College of Cardiology Core Cardiology Training Symposium (COCATS) task force emphasizes the importance of teaching trainees with various educational backgrounds on cardiovascular topics. Peer-to-peer education can be addressed through topic reviews, journal clubs, clinical case presentations and more with the overall objective of imparting knowledge, enhancing communication skills, and fostering a commitment to lifelong learning, and competency maintenance. ² In dermatology, residents must participate in scholarship and basic science and clinical investigation must be included in their residency. In orthopaedic surgery residents must participate in scholarship demonstrated either through sponsored research, peer-reviewed publication, or presentation at a regional or national meeting. ³

To address the research requirements by the ACGME, having a structured research curriculum can be very beneficial. Most programs have the basic elements necessary for residents to conduct research, but do not have a built-in research curriculum. ⁴ Introducing a built-in structured research curriculum has many advantages including increased resident satisfaction, participation in scholarly activities, resident research scholarly production, acceptance into fellowship, and reputation of residency programs. ^{5 6 7}

The Benefits of Research

Research provides a benefit for patients, trainees, and their respective institutions. A summary of the benefits can be seen in Table 1 . The combination and totality of these benefits serve to provide a well-rounded and complete benefit to all involved.

Table 1. Summary of the benefits of research.

Beneficiary	Benefits received
Patient	Contributes to evidence-based medicine Improved patient care Creation of new therapies
Institution	Increases institution rank Increases nationwide appeal Meets ACGME Requirements
Medical student	Career progression Development of critical thinking skills
Resident	Increased residency satisfaction Increased clinical performance Career progression

Benefit to Patients

Resident involvement in scholarly activity contributes to high-grade patient care, leading edge health care practice, and improved patient outcomes. ^{8 9} Evidence-based medicine (EBM), which is the reliance on current scientific evidence to reach medical decisions, has been embraced as the standard to provide care in the clinical setting. ¹⁰ Evidence-based medicine revolves around gathering information and evaluating its validity. Predictably, research serves as one of the foundational aspects of evidence-based medicine. ¹¹ Residents should be able to understand current scientific literature and be able to critically appraise studies to guide clinical decisions in daily practice. ^{1 5} Resident research can lead to improved patient care by cultivating clinical reasoning skills, data interpretation, and a pursuit of lifelong scholarship. ¹² Additionally, a study by Hérbert-Croteau et al showed that those who participated in clinical trials experience a significant reduction in all-cause mortality. This can be due to a variety of different factors including access to new experimental therapies, close monitoring, and rigorous administration of care for both the experimental and control groups. ¹³ The use of evidence-based medicine to improve clinical outcomes can be seen across all fields of medicine. The use of EBM-based guidelines was shown to improve outcomes in patients who underwent brain injury. ¹⁴ Guidelines created through EBM also show improved patient outcomes, decreased litigation, and lowered primary cesarean section rate in the field of obstetrics. ¹⁵ A persistent medication regimen backed by EBM improved outcomes in patients with heart failure as well. ¹⁶

Benefit to Institutions

Annually, the U.S. News & World Report ( USNWR ) provides a rank of the best hospitals and best medical colleges in the United States. They have a set methodology on how they choose the best programs for specific specialties, including internal medicine. ¹⁷ The USNWR produces two distinct rankings one for research and one for primary care. Both are based on faculty resources, academic achievements of entering students, and a qualitative assessment by schools and residency directors. Research activity is used in the research ranking model of different programs and 40% of each school's overall rank. The two components of research activity include total federal research activity, which is the total dollar amount of federal grants a school receives, and the average federal research activity per faculty member, which is the total federal research activity divided by the number of full-time faculty members. Sources of research include the National Institute of Health and the Center for Disease Control. ^{17 18} Both medical schools and residency programs have an interest in pursuing research to bolster ranking and increase nationwide appeal. Additionally, insufficient participation in scholarly activity is a routine cause for residency programs to receive a citation from the ACGME. ¹⁹

Benefit to Trainees

Research provides benefits to all levels of medical training including undergraduate students, medical students, and residents. Undergraduate students build a strong academic foundation through research including critical thinking skills and oral and written communication skills. ²⁰ A survey of medical students showed that a large proportion of students who were positive about a career in research felt that it would enable them to make advances in the medical field. Additionally, others felt that it was necessary for career progression, satisfaction, and an overall integral component of becoming a medical practitioner. ²¹ Another study showed that medical students recognized the benefits of research including the development of critical appraisal, information literacy, and critical thinking skills. ²²

At the level of the resident, those involved in research have been seen to have an increased satisfaction with residency training. ²³ Scholarly production during residency has also been shown to have a positive association with clinical evaluation scores. ²⁴ Additionally, peer-reviewed publications and academic presentations often serve as selection criteria for competitive fellowship training programs. ^{25 26 27} Those who have been involved in research are more likely to pursue a field in academic medicine which can help combine the decreasing amount of clinical investigators. ^{28 29 30}

How to Start Research

There is a certain amount of internal drive needed to get involved in research. It is imperative to seek out the different academic opportunities provided at your institution. Finding mentors in an area of interest is a key first step. Mentors will help you identify a research question you find interesting and then help you answer it and communicate your findings to the greater scientific community. Discussion of the types of research undertaken (i.e., basic science research, translational science research, clinical science research, etc.) is beyond the scope of our document, but should be recognized as an important consideration in the process.

To identify a research question, it is important to immerse oneself in the background literature to better understand the current findings in the area of interest. A good place to start is reading seminal papers and large-scale randomized control trials and meta-analyses pertinent to the research area of interest. There is also value in reading papers from smaller journals that may have focused on more niche patient populations specific pertinent to the research question. Didactic sessions and journal clubs also have value in orienting to different fields of research.

If there is difficulty in creating a novel research question to pursue, then further analysis of a hypothesis noted in another paper may be a good way to start. Researchers may find ways to improve previous experiments or theories. There are always opportunities to broaden research parameters or improve the statistical analyses.

There are two major types of clinical studies: experimental and observational studies. Experimental studies include randomized control trials, randomized controlled laboratory studies, and randomized cross over clinical trials. Observational studies include cohort studies, case–control studies, cross-sectional studies and case reports. Depending on the research question and the type of research being pursued, time commitment, and facility capabilities, the optimal specific type of study can be chosen.

Barriers to Research

Despite the multitude of benefits of research, there are several roadblocks in the way identified by program directors and residents. ²³ Major barriers included insufficient resident interest, limited resident time, paucity of mentors, limited faculty time, lack of resident research skills, absence of a research curriculum, and inadequate funding. ^{19 31 32} The lack of resident interest, in actuality, could be hesitancy stemming from a lack of resources, time, or skills. Residents noted a lack of skills in research activity to be a major obstacle to completing scholarly projects. Not having an appropriate mentor further compounds this issue. Residents also feel that clinical productivity is prioritized over scholarly activity, especially without protected time for research built into the curriculum further impeding the ability for residents to conduct research and bolster their skills. ³³ To increase resident research, it's critical that these factors be addressed by programs.

Methods to Encourage Research

Keeping in mind the barriers trainees face in participating in research, it is important for program leadership to provide academic and technical support. Academic support includes the introduction of a research curriculum and pairing with an appropriate mentor. This can be seen with built in research electives, journal clubs, lessons in statistics, and data analysis and more. The introduction of a resident research program at Baystate Medical Center led to a dramatic increase in department publications from 3 between 2001 and 2006 to 39 between 2006 and 2012. Additionally, they saw an increase in residents accepted into fellowship after the introduction of the program, from 33 to 49%. ⁷ Strong mentorship is also imperative to guide residents through the scientific process. A successful mentor is one that has adequate free time, availability, and commitment to guide resident projects to completion. ³³

Examples of technical support include providing a research stipend for laptops and tablets, access to different statistical software, research consultants and support with data collection. ²⁵ An orthopaedic program at a large academic center in the Midwestern United States recruited an experienced medical editor to help bolster resident scholarship. The addition of the medical editor led to a dramatic increase in publications from 6 to 53 over a 4-year span. ³⁴

Steps to Assure Success in Scholarly Activity

There is increased expectation for residents to partake in research while also fulfilling clinical duties. To ensure success, there are steps that both residency program directors and residents can take. It is important for residency programs to build in a research curriculum to set up residents for success. ^{4 5 6 7} Successful research curriculums address barriers to resident research and these can be achieved through a variety of means including protected time or separative electives for research. Didactic sessions on research skills including biostatistics, research methods, obtaining IRB approval and manuscript writing can work to improve resident confidence and interest in research. ^{31 32} Departmental leadership should help set up residents with faculty who have demonstrated interest and success in mentorship in the past. ³³ Additionally, if a program's budget allows, the hiring of additional staff can dramatically improve scholarly output at a given program. This includes research assistants to help with IRB applications and data entry, statisticians to help with biostatistical support, research nurses to help with data collections, a medical editor to coordinate projects and direct publishing activity, and a resident research director to provide direct mentorship. ^{33 34} Additionally, programs can provide the appropriate technical support to their residents to help with research including access to research facilities, technology stipends, access to statistical software, and reimbursement for travel expenses for conferences and poster presentations. ²⁵

According to a questionnaire given to internal medicine residents who successfully completed a scholarly project during residency training, advice to follow for successful research includes starting early, setting aside an adequate amount of time, adhering to a timeline, working with a strong mentor, choosing a topic that that is interesting, and keeping the research question simple yet innovative. ³² Having a strong mentor is imperative. Working with a mentor leads to higher satisfaction during the residency process and helps keep projects on track during the busy clinical activities of residency. ³³

Conclusion

The benefits of research on medical education are increasingly apparent. Program leaders should encourage and lead the development of a research training curriculum designed to advance trainees' knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. Program directors and leaders in departmental research should also help connect trainees with faculty who have agreed to serve as research mentors and to serve as the liaisons to resolve any problems encountered during the research experience.

Funding Statement

Funding None.