Palabras clave: medical students, medical schools, research, undergraduate medical education

Introduction

“Science is a way of thinking much more than it is a body of knowledge.”        
Carl Sagan

Scientific information flows at a rate never seen before. Currently, everyone lives online 24 hours a day, constantly bombarded with relevant and non-relevant information about multiple topics. Medicine is not exception to this global trend. Everyday dozens of articles are published in different journals and databases, which continue to fuel medical knowledge. Today the world is connected to each other through the Internet, through multiple electronic devices; making it possible to view any information on the time required wherever is required. Nowadays there are examples of how digital information is constantly transmitted to undergraduate medical students encouraging them to seek more digital knowledge and even classes are held virtually or online[1]. However, it is not unusual to find teachers in medical schools still teaching, with old textbooks, medical topics that have already been proven as dangerous or too morbid for patients. These teachers will transmit such information to medical students, the next generation of physicians.

There is a worldwide constant concern about the decreasing levels of the called “physician researchers”.  Students no longer see a career with strong emphasis on research as something feasible for their professional future. Zemlo et al. [2] showed that the number of physician researchers has been dramatically reduced over the past few years, with a further significant decrease on the interest of students to continue conducting research during their professional lives. In Colombia the problem can be even worse. A study from 2002 [3] showed that Colombia only contributes with 2% of Latin America scientific literature. The problem may be more serious when considering Colombia’s own obstacles for proper scientific production [4].

With all this in mind, should the student be solely “consuming” information? Or he also must create medical information?

The aim of this study is to demonstrate the importance of including biomedical research during undergraduate medical education in medical school curriculum. We also aimed to show the relevance of doing research on the future development of the students’ medical career.

Methods

A narrative review of literature was performed in MEDLINE via PubMED with the following search terms: “medical”, “student”, “scientific” “publication”. These terms were used grouped and in different combinations and individually to be able to gather relevant information. We limited the search to articles published in the last 10 years, those who had a full text in English, Spanish or French. The authors selected the articles that were deemed relevant for the topics to discuss: research in medicine, the research hypothesis, research time, teamwork in research and authorship in publications. Additionally articles that were cited by the selected ones were also included if relevant.

Results

A total of 23 articles were found. From these, 16 were chosen for analysis.

The results of the articles are presented and discussed in the different topic sections.

Research in medicine
Research is a high impact topic in medical education. Today, a vast majority of professionals and students are looking for research projects to generate new proposals, innovative ideas and new theories to explain our surroundings. Health professions are not left behind of this trend. In recent years, more clinical and basic science articles are been published by professors, residents and research assistants to add more knowledge in the medical field.

However, beyond the “big name” professors, is there a place for medical students in research? Are medical students potential researchers? Medical students have definitively research potential; moreover medical students are researchers since the beginning of their careers even though they do not know it. The fact that students’ need to search, analyze and solve doubts about the topics seeing in medical school, fulfill the requirements of completing a simple research project. When the students have a question about a specific subject, he performs a research, analyzes the results and is able to answer his original question, and one could argue that he did a small research project. Even more, if the student decides to share his findings with a peer, isn’t that diffusion of knowledge? Medical students start to fulfill some criteria to be considered research while they are in medical school.

It is well known that performing research while being a student, publishing the results - specially in an indexed journal- positively influences the advancement of the students’ career regarding promotion, salary, academic recognition and scientific reputation [5],[6]. Research could help the students secure a postgraduate training such as a residency, and even be the differential factor to get accepted [5],[6].

“The first step in applying the scientific method consists in being curious about the world.”

Linus Pauling

The research hypothesis
Every research needs to have a hypothesis, but what is needed for this? Mainly, some degree of knowledge about the topic to be studied is required. Better knowledge about a topic could identify where research is lacking and allow creating more relevant hypothesis. With a hypothesis, the path to knowledge via a research project in underway, as the scientific method proposes [7]. Scientific method is not exclusive of research, it also helps to diagnose and treat a patient, and could also help the student to think in an abstract, critic way giving him the tools to create relevant hypothesis with the signs and symptoms of a patient.

With this in mind, medical students can acquire the ability to create hypothesis while they are on their clinical rotations. For example, if the student is asked to deliver a seminar about glioblastoma multiforme for one of his clinical rotations, he will look for the information, gather it, summarize important points, after all this musts certainly the student will have doubts about the topic or even he identified “holes” in knowledge about the topic. Now, the student found some research questions (he found the “holes” of knowledge or the article just presented to him as the very common “more research is needed…”) to start a research project. After this exercise, the student could be able to identify a possible research hypothesis.

Construction of new hypothesis has been always a problem for undergraduate and postgraduate students. Not only the lack of interest in doing research is the problem, a lot of the students do not recognize the theoretical concept of a hypothesis. The study by Pawar et al. [8] showed that only 58% of the residents were aware of the research hypothesis concept. One could argue that if the problem is this big in postgraduate education; undergraduate education could have even worse numbers. If students are not familiarized with the research hypothesis and the scientific method, they do not possess the methodological foundation to do research. However, a lot of them are not aware that, despite not knowing the actual definition of a research hypothesis, they are using it every day at the hospital with any new patient. Despite all this, studies have showed that only a third of the questions related to clinical practice are answered with research [9].

All these arguments are in favor of using the scientific method, the generation of a hypothesis in every day clinical practice so that students (undergraduate and postgraduate) are more familiar with the definitions. The first topic for intervention while advocating for medical students research is awareness, students need to be aware of what a hypothesis is and how clinical practice can trigger research.

When to start?
A majority of medical schools have in their curriculum some sort of classes/courses related to research (it could be clinical epidemiology, statistics or research design). Most of them are aimed to help the student to analyze the scientific literature and maybe provided with some foundations for undergoing a research project.

When is the time for the student to do a research project? After finishing those research classes? Or during them? These questions raised concern about the efficacy of the timing of those classes in the curriculum. Let’s take Pontificia Universidad Javeriana curriculum as an example [10]. Undergraduate medical students take a “basic biostatistics” class in their second semester and advance biostatistics in their fourth semester, at the same time they are studying anatomy, physiology, biochemistry and histology, how relevant is knowing what a relative risk is at that point?

Another example would be the ability to look for relevant information in scientific databases; from our experience little is used in those early semesters. Why is that? Primarily, a vast majority of the information needed in those first semesters is in books and the information is enough for that level, it would be very uncommon to see a student looking for a scientific article talking about the normal histology of the liver (to cite a random example).

Romanov et al.[11], performed a survey with medical and dentistry students about the use of electronic databases such as MEDLINE, they found that the use of the databases grew as the students were further in the curriculum. This indicates that databases are more relevant for the students towards the end of their studies. If a student learns to use a database in his first year, but only uses it regularly on the fifth and sixth year of training, years have passed and it is highly probable that the student forgot how to use them. It is not uncommon to find fifth years students who don’t know how to look for an article for a seminar or to study for a clinical topic. We must ask ourselves, is it necessary for a student to learn to use databases while they are in their early semesters? We believe it is not. It is necessary to find a midway point in the medical student formation where he finds the relevance of evidence based medicine, research and clinical practice. The courses approaching research methodology, database use, and interpretation of research, must be taught more closely of the semesters where they are really used. Additionally we propose that it should not be a collection of different courses but rather a scientific foundation block prior to begin clinical rotations. We believe this will favor inclusion of research into clinical practice.

If the student believes in the usefulness of research for clinical practice, he will most likely engage in the same direction.

Research as a personal project?
Research for medical students is often optional in developed countries such as the United Stated or the United Kingdom [12], where, if the student is motivated, he will be able to develop a research hypothesis and start a research project. Students are also able to join ongoing research projects from their professor or the residents. In the majority of the cases, the main focus is on the student and his own curiosity to find a suitable research project.

Should all cases be the same? Or on the contrary, research must be included in the curriculum as a core course?

In Germany, for example, medical students need to perform a research project in order to have their medical doctor title; statistics show that around 66% of the students are able to publish their work in indexed journals [12]. The latter suggests that the research performed by medical students during their studies were of good quality if they were able to publish them in peer reviewed journals. If we try to recreate this model to Colombia, where you have to perform a “mandatory” research project to have a doctor title, universities will need to have the necessary budget (economic and non economic) to support those projects. For this matter, Khan et al.[13] found that research projects are limited by the lack of funds, which finally leads to a lack of interest in research by the students and limit their training [13]. This is a critical point for developing nations such as Colombia (and many others); we need universities and the government working together to gather funds to developed research projects in medical school.

Time for research: reality vs. fiction.
How much time must be dedicated to perform research in medical school? How many years are needed to fulfill a research project?

It is important to remember that research (basic or clinical) requires an almost exclusive dedicated time to do it. The research protocol, gathering data, analysis and finally writing are time consuming. Although these are the “known” factors to take time, one must not forget about the unexpected obstacles in any research project which include the lack of a good mentorship, lack of time due to academic burden, deterioration of research due to a higher concentration on the clinical activities and inadequate methodology in research projects [14].

If the student and the research team have a limited time for research, what should be their real expectations to fulfill a research project? Seasoned researchers know that finishing a project in time is a difficult task, however medical students are rarely aware of this [6]. The study by Cohen et al. [6] showed that students that performed research in one year were not always able to have a publication by the time of graduation. Additionally, they showed that a failure to achieve a personal goal, could lead to stress and negative impact of research during medical education [6].

Teamwork
It is necessary to mention that the student is never isolated in the research world. Moreover, we could argue that research is never a one person endeavor. Students must be aware of the importance of a team while performing research. Teamwork allows dividing the load and delegate thus making recollection of data easier; if the tasks are divided better results are achieved when compared to a single person work [15],[16]. For example, Kaufmann et al. [17] showed that of the 103 publications in the New England Journal of Medicine in 2009, none of them was done by a single author.

The latter is also applicable to the definitive writing of the research project, if you have multiple people verifying the manuscript, a more robust final text will emerge (we could even say it is like a first “peer review” process). A vast majority of the research projects that are currently underway around the globe are performed by teams of experts rather than by a single individual. Anyone who has stepped in a research laboratory knows that there are multiple people involved in the different processes of the research project. This is also valid for clinical research, where different professionals are in charge of the care of the patients, which is basically clinical teamwork.

How can the student join an established team? One answer is to find a mentor. The study by O’Sullivan et al. [18] showed that students with a mentor are more willing to undertake and continue academic projects, some even academic careers in the future. Finally, teamwork needs to also include the institution where the student is affiliated or where the study is done. Universities must support research projects done by their students and function as a solid unique work entity with multiple members of the research team. Teamwork must be in the bigger scale of an academic institution rather than just in the laboratory.

The author
When the student finishes the data gathering, the analysis and the final manuscript, his research is ready to be published. We believe this is a critical step in the young researcher career; he now faces the authorship problem. Multiple studies have showed that professors abuse of their position just to be included in the research projects [19],[20],[21],[22],[23]. Kwok [24] coined the term “white bull effect” which consists in a professor trying to squeeze his name in the authors list without fulfilling the authorship criteria by using his higher academic position, to be included in every article from his clinical department of basic laboratory. Unfortunately, this still happens so we believe the students should follow the International Committee of Journal Editor guidelines for authorship [25]. Following these guidelines will allow the team to know who is an author and who is not.

Even more critical is defining a first author. It is known that the first author is the one with the biggest contribution overall in the research project. Some clinical departments, medical faculties and university hospitals believe that a medical student should not be first author [23]. This, without any doubts, has a negative impact on the student and as it was mentioned before, not fulfilling his personal goals will eventually lead to frustration. Topics such as the authorship of the work must be discussed in advance and have clear guidelines in each laboratory or clinical department. A motivated and acknowledged student will be willing to work on any further research project.

Conclusion

After this narrative review, research is fundamental in the acquisition of knowledge in biomedical sciences. In the medical field, research projects by students have been abandoned due to lack of interest or, even worse, the lack of time and space in the curriculum for research.

It is necessary a change of scope in the different research courses in undergraduate medical education to be able to create a solid research foundations block and the adequate time to fulfill a research project while in medical school so that students will be motivated enough to finish the project.

Critical thinking, creation of a hypothesis, experimentation and teamwork are all abilities needed in every day clinical practice that can be acquired while doing a research project.

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