Comment re: Medical Student Research

Friendly Reply to a Sensible Medicine Post

Jonathan Sutkowski, a medical student, has just written a helpful short post on Sensible Medicine (its like 500 words just read it now) in which he asks two important and related questions: how useful it is for medical students to spend considerable time and energy on research projects during their pre-clinical and/or clinical years? And, more broadly, he invites us to reconsider how we might most valuably spend our limited four years of medical school (it goes by fast!). Here is his articulation of the two problems, from the link above:

As students, we struggle to find time to meet research demands while mastering the curriculum. What’s more, the very research we do is often of little interest. It often takes the form of an analysis of some dataset in the hope of finding a publishable result.

Maybe I am too early in my career for this, but I ask myself, “is this the training path we want for the next generation of academic clinicians?”…

and:

In this article, I want to suggest that we need to clearly articulate fundamental questions for medical training: what does it take to be a good doctor? What does it mean to be a good academic doctor? For the medical student aspiring to these goals, where should his or her focus be during the preclinical and clinical years?

I agree these are important questions we should be asking, especially as technological developments—including but not limited to LLMs/AI—continue apace. He concludes with a qualified perspective and a challenge:

The modern medical student probably does need to spend time on research to succeed in an academic medical center. But understanding what the point of this early-stage research is — in the broader context of a training plan towards becoming an excellent, reliable doctor in a rapidly evolving medical landscape — would give students the opportunity to dive into these experiences with their whole heart.

I’ll state more forcefully what I take the author to be implying much more diplomatically: the vast majority of medical student research is a near-total waste of time. Here I’ll contribute a few thoughts of my own that hopefully add to the discussion in a productive way.

One obvious exception regarding the general uselessness of medical student research is those medical students who go into medical school—especially combined MD/PhD programs—with a clear focus on research, or who truly “convert” to a research orientation early enough. Those students should be encouraged and supported as much as possible, since they’re going to be part of the next generation of serious researchers. I say “serious” researchers because most people who do high-level, significant, productive research in medicine are doing it pretty much full time, not as a side hobby or complement to their clinical practice.

The research-focused students are a minority of medical students, however, and most of us will become clinicians. What relationship should students destined to become clinicians have with research during medical school?

First, my claim that the vast majority of medical student research is a complete waste of time must be considered in light of how we currently spend that research time (or “scholarly time” as it is sometimes euphemistically called) vs. how that time could have otherwise been spent. “I learned a lot of cool stuff, and I got to explore a new area I was curious about” is great, but grinding away hours in a lab or reviewing charts isn’t the only way to explore cool new stuff. Depending on how the research is structured—working some hours per week over many months or years vs. a dedicated research block—time might be otherwise spent increasing proficiency in basic pre-clinical skills, or getting further clinical training on rotations, working at a community clinic, etc.

What is the current status of medical student research? My own experience is about a decade out of date, but I’ll do my best (although I doubt things have changed all that profoundly).

First we should distinguish curriculum-mandated research from extra-curricular research. The latter is often an important part of your CV if you’re going to be applying to highly competitive residency programs. Here students will shop around for mentors (whose reputations will be well known) with research projects in need of a diligent medical student hoping to get published. This is also a potential source of a letter of recommendation, and even a chance to learn some interesting things in a field in which they are seriously considering specializing. The problem becomes acute when, as competition for limited residency spots gets more competitive year by year, the expectations for publishing can ratchet up as students seek to set themselves apart from the rest (not to mention the increasing expectations for all sorts of other extra-curricular activities to pad the CV).

I’d imagine that the USMLE Step 1 exam being changed to pass-fail a few years ago didn’t help this trend, as students applying to competitive residencies will have to find other ways to show their achievements now that a high Step 1 score isn’t an option. Overall, the problem with CV inflation and extra-curricular inflation seems to be a society-wide phenomenon that goes down to K-12. It’s a complicated problem and I can’t tackle it here, although it must first and foremost be acknowledged as a problem. One prescription I will offer here without further elaboration is to start swinging the pendulum back from the extreme “no standardized testing” mentality towards some sane medium that includes rigorous objective testing of various kinds. If medical educators and standardized test writers use AI developments well, standardized testing could become more efficient, orders of magnitude more interesting and engaging for the test-taker, and far more useful in assessing genuine medical knowledge and skill.

Regardless of the question of residency applications, spending “research hours” every week doing endless chart reviews, analyzing data, figuring out how to write a good methods section, or doing bench work is almost certainly irrelevant and counterproductive to a good medical education. These are simply not skills that will be put to good use in the future, nor do they serve as essential foundational knowledge for the development of important future practice. One might counter that many basic science courses in the first two years of medical school are similarly irrelevant by these criteria, but one would be wrong¹. While I don’t use a lot of the explicit knowledge I learned in anatomy or physiology or immunology on a day to day basis—and such knowledge is in principle easy to look up—they formed the critically necessary foundation that allows me to understand all the other important principles of human health and illness, functionally and holistically. It is important to learn how all the parts work and fit together, and then break down, even if your understanding of the Krebs cycle isn’t regularly tested in clinic. The hours spent on most extra-curricular research does not further this kind of general medical knowledge and should be reduced as close to zero as possible, excepting cases in which a student is pursuing it out of genuine passion and interest and would do so even if it was relatively unimportant for the CV.

Next let’s consider the component of research that medical schools write into the curriculum. The amount and structure of the research varies greatly from school to school. Academic centers might heavily “emphasize research”, both genuinely for the students I mentioned above who are going to pursue serious research, but also to provide dedicated time within the curriculum for the non-research students to get publications because the schools recognize it is a necessity for residency applications. To the extent they are doing it for this reason, the argument returns to the problem of CV inflation. Those less research-focused might require you to complete a vaguely defined “research project” before graduating, which can be phoned in more or less easily, or substituted for something like community service. And then there’s all the variance between. Some may have mandated research blocks lasting weeks or months, akin to a clinical rotation. Some, like my alma mater when I was a student, stitched together a mélange of research blocks and longitudinal programs of varying intensity under an umbrella program that was about as messy as these metaphors I’m mixing. That said, my med school class and the few years above and below me were all pretty darn strong and our residency placement was exceptional, so they must have been doing something right.

I’ll conclude with a few thoughts on what an ideal research curriculum might look like for the clinically oriented medical student assuming all pressure to publish was removed. We’re considering only the pure value to medical education.

1. There may be multiple good answers to the question “how much research should be required”, but one of them is “zero”. I suspect many medical school research curricula could be stricken from their broader curriculum entirely and the overall education would not noticeably suffer.

2. Whatever research curriculum exists will be introductory in scope and will likely focus more on the clinical-research interface, including how to effectively communicate with researchers and understanding their relation to your “side of the field”, as opposed to doing any actual “pure research” yourself. There should be no talk of publishing or presenting anything.

3. Keep it short: the marginal value of the curriculum will probably start to decline after a few weeks at most.

4. If students want to imbibe and integrate anything of lasting value, they must first have a decent foundation in biostats, research methods, and an acquaintance with the medical literature and an ability to critically appraise it. This means that research should not be frontloaded in the overall med school curriculum if those prerequisites have not already been taught or tested out of.

5. Most research will remain a bizarre set of oddly related facts if students don’t first have a good foundation in physiology and pathophysiology, as well as some clinical exposure, to give it the appropriate context. First years medical students gain little from doing research on anticoagulant pharmacology or reading JAMA articles on anticoagulation for stroke unless they’re also learning things about the heart and brain and blood and pharmacology as well as actually seeing patients with strokes and bleeds. This is a further argument for placing research at the end of medical school.

6. A limited research block at the end of medical school leaves the option to get acquainted with the research landscape of your chosen residency specialty without fear of having to publish something. You can just see what it’s like to research gastroenterology for a little while, or whatever your thing is.

I suppose one benefit of my own research experience (other than a chance encounter with another med student who later became my wife) was being able to see firsthand, if only briefly, just how all-too-human and fallible and woefully imperfect the entire enterprise is, despite the tremendous aggregate intelligence being put to work on it. As with all human endeavors, however, I remain quite optimistic it is one we can continually improve upon.

Referenced:

Medical Student Research

Improving Your Critical Appraisal Skills

1. Whether those basic science courses are placed at the beginning of medical school, as opposed to at the end or spread throughout in some other way, is another question entirely. I think cramming all the basic science into the beginning of medical school is a mistake, and it should either be back-loaded or spread out. Further, certain prerequisites like biochemistry are probably good candidates for testing out of if you’ve done them pre-med.