Jumpstarting academic careers with a novel intern research rotation: the Academic Internal Medicine Scholarship (AIMS) rotation

The Accreditation Council for Graduate Medical Education (ACGME). requirements for residency education in internal medicine specifically state that the program must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.¹ Further, residents should participate in scholarly activity and the sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities.¹ The scholarly activity requirement may be satisfied with projects other than research, including journal clubs, presentation at grand rounds, and quality improvement projects. Some programs have developed structured research training experiences that prepare residents to present their research at professional or scientific meetings, write manuscripts in peer reviewed journals, and publish review articles or book chapters.² Dedicated research activities advance the core competencies and are often highly rated aspects of residency training.^3–5 In fact, most residents feel research should be required.⁶ A recent article suggests that residency program enhancements in patient care, education, community service, and research improve departments of internal medicine and teaching hospitals.⁷ Finally, research experiences may encourage some residents to consider a career in clinical investigation.⁸ Despite these potential benefits, implementing a structured research curriculum in a busy residency program remains a logistical challenge.

In a meta-analysis, Hebert and colleagues⁹ identified four features of successful resident research programs: exposure to and guidance from mentors, training in basic research methods, protected time, and an environment supportive of research. The vast majority of internal medicine programs offer one to two months of protected research time during postgraduate year (PGY) two or three. An informal email survey of the Association of Program Directors in Internal Medicine (APDIM) listserver participants showed that 121 of 143 programs, or 85%, offered at least four weeks for research. However, successful resident research projects require much greater commitment of time, interest, and resources. Pursuit of research interests is often displaced by patient care demands.¹⁰ We previously described resident research as a three-year continuum of preparation, investigation, and synthesis phases in which early preparation is critical.¹¹ Delaying bona fide research experiences to PGY-2 and compressing them into a one-month block, along with an often ad hoc search for mentors, limits the resident’s chances for success. Such frustrating research experiences may even deter residents from careers in clinical investigation.

We recently implemented the four-week Academic Internal Medicine Scholarship (AIMS) rotation, which introduces all interns to the process of organized inquiry and research. Each intern designs a feasible, scientifically sound research project to be completed over the course of residency. They learn research methodology, cultivate mentoring relationships, and develop interdisciplinary collaborations. Since 2005, all interns in the categorical internal medicine residency program at University of California, Davis, School of Medicine (UC Davis) have completed this rotation. We describe the early success of this novel research curriculum. This project has been approved by the UC Davis Institutional Review Board (IRB).

Program Description

The UC Davis internal medicine residency is a medium-sized urban university program. Our 87 residents rotate through three inpatient sites (University Hospital, Northern California Veterans Affairs Hospital, and Kaiser Permanente) and two outpatient sites (University Hospital and Sacramento County Clinics). Approximately 60% of residents go on to subspecialty fellowship training.

The AIMS rotation occurs in the second half of the intern year and is intercalated into a four-week ambulatory care block. Although originally conceived as a dedicated research-only experience, integration into an ambulatory rotation emphasizes the interdependence of research and patient care and allows other program requirements to be met during the month. Interns acquire basic research skills through proposal development, oral presentation, and exploration of methods for data collection, collation, and analysis. The rotation consists of facilitated small group research discussions, live and online lectures, and protected time for consultation; interns continue to participate in required residency core didactics and clinics (Figure 1).

Figure 1.

Sample 4-week schedule for Ambulatory Internal Medicine Scholarship (AIMS) Rotation

*AIMS includes facilitated small group discussions, lectures, and protected time for consultation and viewing online content.

^core didactics refers to required residency didactic conferences.

The AIMS rotation runs in collaboration with the National Institutes of Health (NIH)-funded Clinical and Translational Science Center (CTSC) at UC Davis Health System. The CTSC education officer (CSH) and the associate program director for research (TLF) coordinate the rotation. Lecturers and mentors include experienced faculty researchers, biomedical informatics experts, clinical research coordinators, biostatisticians, medical librarians, research bioethicists, science and grant writers, librarians, research nurses, and IRB personnel. Beyond lectures and individual consultations, interns meet in weekly small groups with research faculty to discuss challenges and report progress. A rotation website serves as a repository for course material, including prior research proposals and presentations. Interns are encouraged to attend the regularly scheduled CTSC research seminars and workshops. During the final week of each rotation, interns present their research plan at the AIMS research forum. The audience often includes the department chair, - program director, CTSC core directors, research mentor, consulting biostatisticians, and fellow residents. All audience members provide oral and written feedback, which is given to each intern in summary form.

The rotation objectives are similar to other residency research curricula.^9,12 Interns learn about research design, biostatistics, human subjects protection, institutional resources, and epidemiology through lectures and individual statistical consultation while developing their proposals. Attitudinal objectives include promoting intellectual curiosity through scholarly investigation of clinical questions and enhancing residents’ appreciation of biomedical research. Skills objectives include proposal development, scientific writing, and presentation skills. Process objectives include exposure to successful researcher role models and IRB members. In terms of the ACGME core competencies,¹ the rotation adds to the intern portfolio in practice-based learning, medical knowledge, interpersonal and communication skills, system-based practice, and professionalism (Table 1).

Table 1.

Competencies addressed in AIMS

Competency	Accomplished by:
Practice Based Learning	Identification of a topic from clinical experience. Use of quality improvement strategies or chart review to examine local practice.
Medical Knowledge	Integration of comprehensive background data, specific aims, hypothesis, biostatistics and study design into proposal.
Interpersonal Skills and Communication	Cooperative and interactive style during small group sessions, clarity of presentation of proposal at research forum, ability to address audience questions and clarity of written proposal. Evaluation by mentor.
System Based Practice	Integration and use of local resources in proposal.
Professionalism	Completion of NIH training in protection of human subjects. Timely completion of all rotation requirements.

Our long-term objectives are to increase residents’ scholarly productivity and promote a culture of scholarship and scientific inquiry within the program. Interns requesting dedicated research time during PGY-2 must submit a revised proposal and obtain written approval from their mentor and the Residency Research Committee (which includes the program director, associate program director for research, department chair, a CTSC leader, and a senior faculty researcher). Residents who meet this requirement may take a four-week research block during the PGY-2 and PGY-3 year. The Department of Medicine budgets $750 for each resident to prepare an abstract and present it at a regional or national scientific meeting. Travel costs are generally shared by the faculty mentor. Other programs fund up to $1,000 per accepted research submission.¹³

Preliminary outcomes

The success of AIMS can be assessed in several ways. A traditional academic benchmark of productivity is the number of scholarly presentations, awards, manuscripts, and grants. As of January 2009, 74 rotation completers have presented 50 case reports and 15 research abstracts at regional or national professional meetings (Figure 2). In just three years, we have seen an increase in research abstracts and a decline in case reports. Residents have won eight research or case report awards at regional meetings. Successful publication of manuscripts is harder to accomplish during residency, but completers have already published two papers. One resident has received a competitive American Board of Internal Medicine Foundation research grant and two are pursuing federally-funded research fellowships. Our first AIMS class graduated from residency in 2008, so we continue to measure success by tracking presentations at professional society meetings, publications, and rotation specific outcomes. For the long term, the number of residents who ultimately pursue research careers will be tracked. An intermediate outcome is the proportion of interns that complete a hypothesis-driven project. Of the 74 interns who have completed the AIMS rotation, 46 (62%) went on to complete projects during a PGY-2 research block.

Figure 2. Productivity outcomes to date.

Number of research abstracts and case reports presented and awards received by residents who have completed the AIMS rotation. The total number of residents (N) is included.

* Represents an incomplete academic year; only 4 of 24 interns have completed the rotation, which occurs during the second half of the year (data as of 02/03/09).

Even if they do not ultimately pursue an academic career, residents with research experience or skills may be better informed consumers of the medical literature. Interns’ self-reported knowledge, skills, and attitudes improved in almost all areas, including modest gains in the writing and statistical domains (Table 2).

Table 2.

Change in intern (n=69) self-reported outcomes before and after AIMS rotation

Knowledge (1–5 scale where 1 is a strongly disagree and 5 is strongly agree)
	Beginning of intern year	End of intern year	P value*
I knew/know of at least one person I could go to with a research proposal idea.	2.7	4.4	<.01
I knew/know how to find a mentor to help with a research program at UC Davis.	2.5	4.1	<.01
I had/have a good grasp of the resources available to me to conduct research at UC Davis.	2.0	3.9	.06 (NS)
I knew/know how to contact the IRB.	1.9	3.8	.04
I understood/understand the importance of the IRB in protecting human subjects.	3.3	4.3	<.01
Skills (1–5 scale where 1 is a poor and 5 is excellent)
Grant writing	1.7	2.1	<.01
IRB regulations	1.9	3.1	<.01
Literature searching	3.1	3.8	<.01
Manuscript writing	2.2	2.8	<.01
Research design	2.3	3.2	<.01
Statistical analysis	2.0	2.5	<.01
Attitude (1–5 scale where 1 is a strongly disagree and 5 is strongly agree)
I plan (or planned) to do research during residency	3.8	4.2	<.01

^*paired T-test to compare the means

Although we do not have other non-clinical rotations with which to compare, interns have rated the overall experience highly (8.5 on a 10-point rating scale), including the adequacy of time allotted to proposal development. Rotation completers have commented positively on the value of completing research proposals and collaborative small group learning, and reported a renewed appreciation for the challenges of research. Numerous residents have also secured resident travel awards from national organizations including the American College of Physicians, America Association for the Study of Liver Diseases, American Society of Hematology, American Academy of Allergy, Asthma and Immunology, and others.

Discussion

We describe a structured a research experience that promotes development of the ACGME core competencies, is well received by residents, and ultimately may encourage more residents to pursue a career in clinical investigation. Resident success is often hampered by key early steps such as formulating a question, finding a mentor, and understanding basic research design and methodology. Early structured support of research allows residents to efficiently accomplish these tasks rather than taking several months or more to complete them on an ad hoc basis. We have previously described three phases of resident research (preparatory, investigatory and synthesis) which may take three years to complete (Figure 3).¹¹ Our AIMS research curriculum allows residents to complete the preparatory phase during internship. Requiring every intern to develop a research proposal has several advantages: 1) interns are better prepared for research electives during the second and third year of residency; 2) residents learn early in their careers how to report scientific findings; and 3) the culture of the training program may be transformed as research becomes an integral part of residency training. Over 60% of our residents begin the investigatory phase during a protected research block in PGY-2 or PGY-3, a much higher proportion than the 20% reported by internal medicine program directors.² During the research block, residents meet with their mentor, the associate program director for research, CTSC staff (data management and biostatistics support), and medical librarians (reference management tutorials). Residents who take a research block also present their research findings at the annual department Academic Forum, which is attended by community members, faculty, and fellows. Residents then move into the synthesis phase during their PGY-3 year and also dedicate substantial time to writing outside of their research block.

Figure 3. The Three Phases of Resident Research.

Adapted from Hamann KL, Fancher TL, Saint S, Henderson MC. Clinical research during internal medicine residency: a practical guide. The American journal of medicine. 2006 Mar;119(3):277–83.

In the three years since the program’s inception, we have observed a culture change that includes an expectation for high-quality scholarship and presentation at local, regional, and national meetings. Pediatrics and anesthesiology residents now participate in the AIMS rotation.

Structured research programs encourage interns to access and interpret the medical literature, practice oral and written scientific communication skills, and participate in a multidisciplinary research team. Successful research adds to the resident’s portfolio and enhances fellowship and future employment opportunities. Interns discover opportunities for research and support for clinician-scientist careers through collaboration, critical components of the NIH investigator road map.¹⁴ Training programs gain a population of local resident experts, regional and national exposure, and a scholarly reputation that may enhance resident recruitment.

Developing a resident research program presents a number of challenges.¹⁵ Finding curricular time for new programs within an already stretched residency programs is not easy. Collaboration with departments and careful integration into the ambulatory block rotation may ease these concerns. Interns may be resistant to doing research while in the midst of intense clinical training. In 2004, we piloted the rotation with two highly motivated residents during an elective block, allowing us to develop the rotation on a small scale. In the absence of a contemporaneous control group, we cannot definitively conclude that the satisfaction and increased number of projects is due to the AIMS rotation alone. We suspect, however, that the formal curriculum has had a significant impact. Cultivating a cadre of committed enthusiastic faculty and hiring an associate program director for research to mentor the residents are critical for success.^16,17 Programs without a CTSC should consider seeking help from other institutions or graduate programs. To promote a culture of scholarship, we have required that all internal medicine interns participate.

The AIMS rotation is a structured research experience for interns that increases the likelihood that residents will complete a hypothesis-driven research project during residency. Regardless of their ultimate career, the experience likely enhances residents’ appreciation for scholarship while contributing to the development of several ACGME competencies.

Perspectives Viewpoints.

The Academic Internal Medicine Scholarship rotation promotes development of the ACGME core competencies, is well received by residents, and ultimately may encourage more residents to pursue a career in clinical investigation.

In the three years since the program’s inception, the culture has changed to include an expectation for high-quality scholarship and presentation at local, regional, and national meetings.

As interns discover opportunities for research and support for clinician-scientist careers through collaboration, training programs gain a population of local resident experts, regional and national exposure, and a scholarly reputation that may enhance resident recruitment.