Educating future clinician academics: the role of medical schools

No consensus on research skills in medical curricula perpetuates the unmet need for clinician researchers

Despite increasing emphasis on research translation, underpinned by the growth in hospital- university health precincts (“academic health centres”), there is a persistent and unmet need for clinician researchers in Australia and New Zealand.1^,2^,3 Such careers and the relevance of learning research remains opaque to medical students, and expectations for graduate research competencies are unclear. Unlike clinical skills, there is no consensus on the research skills that Australian and New Zealand medical graduates should acquire.4^,5 Australia is not alone; these gaps are reported internationally with calls for better defined core competencies in research that would enable purposeful design of learning outcomes and assessment.4^,6^,7 Although an absence of agreed expectations for research training is seen across the continuum of undergraduate to specialty education and training, this article focuses on primary medical education for all medical students, only some of whom will become clinician researchers.

Learning about evidence‐based practice and research principles is accepted as essential and is standard in medical programs around the world.8,9,10 However, interpretations of what is sufficient or acceptable research competency varies greatly; from theoretical applications of basic literature searches and critical appraisal skills to dedicated curricular time for conducting an independent research project.11

Australia has three codes or standards which give guidance on research training to be provided in medical degrees8,12,13 (Box 1).

In 2011, the University of Melbourne was the first Australian medical school to transition their medical program from the traditional Bachelor, Australian Qualifications Framework (AQF) Level 7 (eg, Bachelor of Medicine Bachelor of Surgery MBBS) degree to the Doctor of Medicine (MD) AQF Level 9E (Extended) Masters degree. AQF 9E stipulates graduates must undertake “some independent research and a significant proportion of practice‐related learning”.13 A 2019 survey by the Medical Deans of Australia and New Zealand (MDANZ) showed that all 23 Australian and New Zealand schools, regardless of whether teaching an MD or an MBBS, consider research as essential in their curricula.5 However, there was inconsistent interpretation of the Australian Medical Council’s research‐related Graduate Outcomes.8 Examples varied from mandatory research projects completed by individuals or groups, to courses on statistics and research methodologies, to application of critical appraisal and evidence‐based medicine skills to published studies.

Gaps in interpretation

The largest gap is that between what happens in medical school and the unmet demand for clinician researchers, and in part is due to uncertainty about how to adapt and meet research expectations for different medical school contexts. Respecting each school’s values and goals begs the question of whether it is desirable or even possible to have standardised research skill requirements.4 Variation is evidenced in how research experiences and learning are delivered between schools,14 leading to challenges in assuring comparable student learning across different sites. Moreover, research experiences should be positive and meaningful to clinical careers to avoid demotivating future involvement in research. Should research experiences then be considered as a core learning outcome, alongside clinical placements? This would promote clearer definition of research skills and how they map to graduate outcomes15 and graduate practice. We argue that the acquisition of core research skills assists with integrating scientific evidence into clinical knowledge translation and is thus relevant to both clinical and research‐oriented careers.

Preparing medical graduates to be research work‐ready

Some may ask why research competency is needed for interns to be work‐ready for health service workforce needs. In its broadest sense, being research work‐ready as it pertains to graduating medical students means being research literate. Research literacy is a relatively new term that extends evidence‐based practice16 to knowing the methods of enquiry to gather evidence. Being research literate includes the ability to locate, comprehend, discuss and evaluate a variety of research, convey its meaning and implications, and use the findings appropriately in health care.4,7,9,10,11,17 Working backwards from this graduate outcome, the foundational knowledge, skills and core competencies needed to achieve it can be defined.

Recommendations

This concept of research work‐readiness might assist with consistent interpretation and agreement on what should be the core research competencies for Australian and New Zealand medical students. From this, comparable learning outcomes and curricula can be designed and implemented across medical schools with different expectations for their graduates. Rather than a universal approach, we suggest the following principles when reviewing research education for medical students.

Benchmarking. The literature is replete with systematic reviews, student survey data and reports of exemplar programs suggesting what research skills and competencies medical students should acquire,4,6,15,17 but no agreement on what competencies all students should achieve, giving the impression that research is optional. We suggest curriculum designers explicitly benchmark their program to a published framework, or through peer review with comparable programs. For example, programs differ in emphasis on clinical career and patient care or on academic outputs such as research reports and publications when deciding what to include in crowded curricula.

The wide variety of research experience and interest among medical student entrants is an important consideration. Even though many students in graduate programs have a bioscience degree, some will have MScs, PhDs or prior employment in industry. Configuring a curriculum so that it encourages all students to embrace research skills as essential to evidence‐based clinical practice and to be ready to use these skills in patient care is achievable and expected of any medical program.

Experiential learning is the most effective way to acquire work‐related graduate skills and we propose that research experience can be realised in many ways. Medicine is grounded in the scientific method and how knowledge is justified and evolves through each step of the research cycle.7 These steps are activities that can be designed and delivered as competencies acquired through a variety of educational approaches and in different environments, and thus develop research literacy in medical students (Box 2).

Mission and context. Each school’s unique mission and context should inform the stated purpose of including research in the curriculum. In the same way that mission and context inform how medical school accreditation standards are applied to governance, teaching and program evaluation, so they should influence research education. For example, a socially accountable ethos demands community‐engaged research, and research impact to be monitored and evaluated against this mission.

Research environment. The research environment will vary according to the university in which the school is located, from research‐intensive Group of Eight universities (https://go8.edu.au) to new medical schools in regional or underserved settings. Research institutes are not the only source of quality research education and supervision. Rural communities offer a wealth of interdisciplinary and research translation strengths that might be more fit for purpose in a rural medical program.18 Such outcomes and aims are not easily measured with quantitative research metrics, which promote unfair comparisons and overlook the strengths of socially accountable medical schools. In these settings, real achievement means building research capacity through community partnerships that lead to improved community health over time. Regardless of a school’s mission or baseline research capacity, student research competencies should be achievable and adaptable to varied learning environments.19

Collaborations. Cooperation and support from both hospital and community health systems need to be strong. For example, the gradual development and evolution of research relationships in primary care and with community partners can generate many project‐based learning opportunities during and outside of placements. Students can bridge the process of establishing partnerships by contributing to community programs, thereby growing research capacity and providing mutual benefits. This approach also holds promise for addressing the so‐called real gap in Indigenous health. Through partnerships founded on reciprocity and respect, medical students could apply research skills to conduct studies ranging from grassroots development projects to program evaluations, and engagement studies.20

Time. Making time for research skill development is important to a positive research experience for medical students.4,15,17 More challenging is how to move thinking beyond clinical placement versus research time binaries to integration of research education into clinical learning. Rather than research time being an opportunity cost in clinical learning time, clinical learning is an opportunity to learn research. Integration means learning research in settings other than laboratories, and moderating expectations of students conducting all steps in the research process and publications as measures of research worthiness. Flexibility in defining research as scholarly experiences, as allowed by the AQF 9E designation of a professional, rather than research masters qualification, highlights career alternatives in education and/or leadership and could include training in quality improvement methods for clinical and community services (Box 2).

Mentorship. Longer term mentor–mentee relationships are widely accepted as beneficial when joining a disciplinary community of clinicians. We suggest the same with researchers, to help medical students see that research skills are part of having a sense of curiosity or habits of mind, if not a career in research. For some students, making realistic choices about early involvement in research alongside their medical program might create a dilemma. Mentors could help students understand how research they conduct contributes to the science of the medicine they are studying, rather than just as projects and publications. Medical schools should support options that are clearly relevant to future roles as clinicians, educators and/or leaders, as well as research roles.

Curricula that include personalised guidance can thus assist students to balance competing demands and nurture individual interests. Importantly, offering core research learning and guidance to all students could widen access to academic careers for students from groups under‐represented in the researcher and clinician academic community. Even though the pool of mentors and research supervisors is limited, it is unlikely to increase without giving more credence to graduating all students with core competencies and capabilities in research.

Sharing best practice and exemplars. Research managers have become professionalised, but there is no equivalent group for research educators. A professional network or interest group could develop best practice and advance a shared understanding on required competencies. Informed by practical teaching experience, such groups can develop strategies for achieving core competencies for research readiness without needing to deliver the same program or learning activities across diverse locations. The recently launched MDANZ Case Studies Annual Series is one example of a platform for disseminating exemplars and best practice in medical school research education.18

In conclusion, better defining what should be core research skills in Australian and New Zealand medical curricula is now needed. Views from research educators, researchers, clinicians, university academics, postgraduate trainers, and health service and community stakeholders should be included to develop a consensus statement on medical graduate research competencies relevant to our context. This will lead to greater clarity for curriculum and program designers and teachers and, importantly, to greater awareness of the place of research in future careers for the students and graduates of our medical schools.