Our contemporary curriculum can foster in medical students and residents a very distorted view of research. Most of medicine is taught in a largely ahistori-cal manner, and students can easily develop the impression that most of the information available at their fingertips in contemporary textbooks of medicine was plucked from the trees of nature like low-hanging fruit. We are so busy stuffing new facts into their heads that we often allow the content of medical science to overwhelm its methods, so that learners gain little understanding of how medical knowledge is uncovered in the first place. They may think of the biomedical research enterprise as a large machine that keeps churning out new knowledge as long as we maintain its parts in working order and provide it with fuel. In fact, however, medical knowledge is the direct product of human dedication and ingenuity. Only if bright and curious people are recruited into medicine and encouraged to pursue careers that incorporate a substantial commitment to research will medicine as a whole continue to thrive. The quality of medical research is constrained by the quality of the people doing it, and we need to continue to attract our best and brightest into the field.
What steps can we take to promote research as an important professional opportunity for medical students and residents? First, we need to study how our learners understand the very meaning of the term research, and its relation to a closely related term, science. Second, we need to better understand why more of our best medical students and residents are not choosing research careers. Why are National Institutes of Health grants increasingly awarded to PhDs instead of MDs? What can we do to increase the attractiveness of careers that incorporate a substantial research component? What practical steps could medical school faculty members, residency program directors, and medical school deans take to bolster the future of medical research?
To begin with, we need to better understand how medical students and residents understand research. Some enter their training with substantial research experience, and others acquire it during their education. These are not the learners we need to worry about. Many other learners, however, have little or no formal research experience. All have done laboratory exercises in their collegiate natural science courses, but in many cases such exercises represent "cookbook" sort of experiences where students simply follow directions to arrive at predetermined solutions,without seriously investigating anything new. Many of these students do not know what it means to formulate a research question, how to devise means of testing a hypothesis, how to pursue funding, how to collect data, or what the day-to-day life of a researcher is like. They may not know which faculty members are actively engaged in research, or what they are working on, in part because many members of the faculty do not share it with them.
Ask such students and residents to describe science, and many will point to journals or books on a shelf. They regard science as the sum total of everything we know. When they think of doing research, they picture themselves holed up in the library, trying to commit to memory the facts contained in their textbooks. They see science, in other words, like studying for an examination. How many medical students and residents see science as an ongoing investigation, a way of asking questions instead of a collection of answers? This is a superficial and ultimately counterproductive understanding of science. It does not prepare learners to become investigators, nor does it prepare them well to play the role of critical appraisers of the scientific reports of others. If we are to redress these deficiencies, we need to help students gain a clearer understanding of the meaning of research and the larger scientific enterprise of which it is a part. A critical means of doing so is to provide students with first-hand investigative experience.
What can faculty members do to help? First, we can encourage learners to ask questions during their clinical work, and to think of those questions as potential research projects. We need to value them as much for the quality of their questions as we do for the number of questions they are able to answer correctly. Second, we need to ensure that learners know which faculty members are committed to research careers, and make sure that researchers share their work with learners. Third, we need to cultivate opportunities for students and residents to become meaningful contributors to ongoing research projects within our departments. Finally, we need to make sure that medical students and residents have the encouragement and support they need to begin working on research problems of their own. For example, substantial research expectations might be integrated into the graduation requirements for medical schools and residency programs. In the short term, such a policy might represent inefficiency in the production of clinicians, but in the long term, it could enrich our medical knowledge and thereby improve the quality of practice.
Many medical schools and residency programs place most or all of their emphasis on clinical work. Students and residents are evaluated based on their clinical work, the curriculum is designed to make them good clinicians, and the faculty members model the clinical role, not that of the researcher. If the faculty cares little for research, we should not be surprised that its appeal to learners is limited. Yet whether they know it or not, the ability of learners to practice good medicine hinges on the quality of research available to guide practice. If they don't engage in some form of research as medical students, they are less likely to do so as residents. If they don't engage in research as residents, they are even less likely to do so as practicing physicians. Hence it is important that we reach learners early, at the most formative stages in their careers, and encourage them to try their hand at research.
An especially pernicious notion among both medical students and residents is the view that you must tell interviewers that you are interested in research if you hope to get the best residency or fellowship position. This is dangerous first and foremost because it abets mendacity, which cannot be salutary for the profession. Yet it may also reflect an important perception on the part of many learners that research offers few if any rewards. They see quite easily the rewards that flow from clinical practice, but the rewards of research may be relatively hidden. By fostering more interaction between learners and investigators, we can promote a better understanding on what research has to offer. What kind of excitement is involved in first-rate investigation? What sort of fulfillment flows from making a contribution to medical knowledge that changes the way patients are cared for? What sort of teamwork and camaraderie can working on a research project inspire?
We do medical students and residents, as well as our whole profession, a disservice when we foster the view that learners lack sufficient time and energy to learn merely what they need to know to be passable physicians, let alone researchers. They can become so preoccupied with performing well on clinical tests that research quickly fades into the background of their professional agenda. Which is more threatening to a medical student: performing poorly on a clinical rotation, or failing to participate in any meaningful way in research? The intellectual agenda becomes dominated by doing well on their clinical examinations, which in turn are dominated by extant knowledge, and the creation and even critique of new knowledge ceases to be much of a priority.
Yet research and clinical competence are far from unrelated. An active research program can foster major improvements in clinical practice,by making us think more carefully about what we do for patients day to day. We may become more observant of the effects of our recommendations, more critical about what we see recommended in the journals and textbooks, and more up to date on the latest developments in our field. We see ourselves not as the passive repositories of medical knowledge, but active contributors to the field, whose ideas may change the way things are done. Try this experiment: ask a medical student or resident what he needs to know to be a good doctor. Many of them will point to a stack of pocket manuals or textbooks. In fact, however, we need them to point with equal conviction to medical journals, laboratories, and ongoing clinical investigations.
When we evaluate medical students and residents, we need to take into account not only how many facts populate their memories, but their knowledge of the scientific method, scientific literature, and critical thinking. We need to think of them as creators. Examinations should stress this aspect of medicine to a greater degree than they currently do, and our standard evaluation forms should include this perspective. If medical students and residents expect to be evaluated along these sorts of parameters, they are likely to attend more closely to them in establishing their learning objectives and allocating their time and energy. If research is not something learners expect to be evaluated on, they are likely to pay less attention to it. Another helpful step in this direction would be to provide recognition and even support for learner research efforts.
Merely mouthing platitudes about the importance of research is not enough. We can talk about research all we want, but if the culture of the department and school says that clinical service is what it is all about, research will tend to suffer. We need to make sure that we offer role models of successful physician-researchers. When we teach learners at the point of care, we need to encourage the formulation of good investigative questions. Journal clubs are an important opportunity for medical schools and residency programs, because they develop habits of reading and critically appraising the medical literature. What if every week, or every month, or every quarter, every medical student and resident were asked to give a five-minute presentation on a new research question he or she had identified, including why it is important and how one might go about beginning to investigate it?
We need to move medical students and residents from an educational model in which most of them are strictly consumers of medical science and help them gain experience at producing medical science. Where they remain consumers, we need them to become critical appraisers of what they hear and read. When they ask probing questions, we should encourage them, not shut them up in order to avoid exposure of our own ignorance. If the future of medicine closely resembles the present, we will have failed as researchers, and if today's learners do not play an active role in helping to avoid that fate, we will have failed as educators.
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