[The following notes were generated by Sandra Haudek, PhD.]

The Winter 2022 IAMSE Webinar Seminar Series, titled “How Science Educators Still Matter. Leveraging The Basic Sciences for Student Success” continued with its second seminar on Thursday January 13, 2022, titled “Research in Medical School – Impact on Career Path”. This seminar was presented by Dr. Rachel Wolfson, Assistant Dean of Medical School Research and Associate Professor of Pediatrics at the University of Chicago Pritzker School of Medicine. Using data from the medical education literature and the National Resident Matching Program, she discussed the impact of medical student scholarly activities on their skill development and career trajectory. She also debated how scholarly research might be addressed in the residency application process, including how program directors might use research participation and productivity as proxy measures of desirable characteristics among program applicants.

Dr. Wolfson started with discussing the landscape of medical student research participation. She explained that research during medical school is increasingly common and often supported by structured scholarly concentration programs providing protected time, dedicated mentors, and benchmarks for completion. However, a comparison of medical school curricula is difficult due to different elements such as optional versus required research projects, amount of protected time, nature of essential deliverables (e.g., poster versus published manuscript), different tracks in which inquiry projects have different emphasizes, and the definitions of what counts as scholarly (e.g., hypothesis-driven, statistical analysis). She points out that critical thinking skills can be learned from many different projects, and that these projects do not need to be a basic science research project. She further mentioned the Scholarly Concentration Collaborative (sccollaborative.uchichago.edu), a multi-center collaborative aimed to improve and grow opportunities for student research and discovery. Using AAMC medical school graduation questionnaire data of the last 6 year, she showed that with the number of medical research opportunities also the number of publications and poster presentations increased. Lastly, Dr. Rachel reviewed several papers that measured the impact of research on medical student education in single-center studies: Clin Trans Sci 2015, 8:479-483; Acad Med 2017,95(8):1196-1203; Acd Med 2018, 93:1727-1731; J Investing Med 2019, 67(6): 1018-23; Med Educ Online 2020, 25(1):176210; Acad Med 2012, 87:1582-1593. All discussed studies showed a positive correlation of research fellowships with increased number of publications, better residency match results, and more likely to attain academic positions.

Dr. Wolfson then continued with discussing the impact that research participation has on student career trajectory. She debated if students should do research during medical school? Her institution’s curricular goals are the following: Become critical scientific thinkers (hypothesis, approach, evaluation, dissemination), develop self-directed learning skills, and develop and sustain interest in career-long research even if these students do not become NIH-funded researchers. Yet when medical students were asked about their goals, they listed “developing a strong mentoring relationship with a faculty mentor” and “enhancing competitiveness for residency match” above any skill development goals (Medical Education 2017; 51(8): 852-860). Listing anecdotal but consistent data, Dr. Wolfson further elaborated on students’ concerns which included: Success in research is important in highly competitive specialties and probably even more important when USMLE Step 1 becomes pass/fail, thus publications or scholarly work in these competitive fields of interest (not in other fields) are critical. Yet research projects are not always possible or easily attainable in such fields, and/or at the beginning of medical school, students do not know yet which specialty they will choose.

Dr. Wolfson then discussed how resident program directors regard scholarly work in evaluating applicants. She reviewed several papers addressing the program directors’ point of view. One large survey study from 2009 indicated that scholarly work was at the bottom of their selection criteria, yet was decisive for ranking when all applicants were “outstanding” in their score criteria (Academic Medicine 2009, 84:362-367). She then lists a sampler of several specialty-specific studies indicating that the emphasis on research as an important selection criteria increased over the last years. Lately, the concern arose that when Step 1 goes pass/fail, students will look more similar and research may be emphasized even more. This leads to the question if today’s goal to include research in the medical school curriculum is really to educate future researchers or is actually to enhance residency matching? And further, is success in research an independent variable, or is it a proxy for another applicant characteristic, such as for enhanced communication and teamwork skills, intellectual curiosity, perseverance, or commitment?

Dr. Wolfson then reviewed data from the National Resident Matching Program (NRMP). She first presented the 2020 match data illustrating the mean number of research experiences of US medical students correlated to matching results per specialty field. These data showed very clearly that only in the highly competitive specialties, such as dermatology, neurological surgery, plastic surgery, and radiation oncology, students who matched had more research publications and poster presentations than students who did not match. Dr. Wolfson then continued with a discussion of the NRMP program director survey 2021. Interestingly, NRMP groups the criteria “involvement of research” and “interest in an academic career” not under the “education and academic performance characteristics” but under the “personal characteristics and other knowledge of applicants”. The data then indicated that only 41% of program directors scored the first criteria and 24% the second criteria as important decision factors for selecting an applicant for an interview. Even fewer program directors considered these two criteria as important for ranking applicants. To highlight these trends, Dr. Wolfson further discussed the breakdown data for neurosurgery, dermatology, and pediatrics as examples. Lastly, she mentioned that, as part of the Scholarly Concentration Collaborative, her team is currently involved in a similar, still ongoing study. In this study, they are surveying >5000 program directors with the goal to understand and describe the relevance of medical student research among residency program directors. Their goal is to obtain more details as to what type of research and in which specialty field research may be important, and how this will change with USMLE Step 1 going pass/fail.

In conclusion, Dr. Wolfson summarized that the USMLE step 1 score was important for getting an interview (which, unfortunately, may be USMLE step 2CS in the future), but other characteristics such as scholarly work, including number of research presentations and publications, were decisive for ranking especially in highly competitive specialty fields. This emphasis on research may intensify even more, as well may become visible on other less competitive specialties once USMLE Step goes pass/fail. Dr. Wolfson then stated that scholarly concentration programs are opportunities for mentorship, role modeling, teaching beyond project completions (soft skills), and balance between critical thinking, research development, and success in residency match. The presentation lasted about 45 minutes, followed by a lively discussion addressing questions from the audience. These questions probed if students should take a year off before, during, or after medical school to do scholarly work, and how students deal with the effects of the pandemic during which scholarly research may have been less accessible.

[The following notes were generated by Sandra Haudek, PhD.]

The Winter 2022 IAMSE Webinar Seminar Series, titled “How Science Educators Still Matter. Leveraging The Basic Sciences for Student Success” opened on Thursday January 6, 2022 with its first presentation, titled “New Horizons: Restructuring the basic and clinical sciences beyond USMLE”. This seminar was presented by Dr. Nadia Ismail, Senior Associated Dean of Curriculum, Dr. David Rowley, Assistant Dean of Foundational Sciences, and Dr. Munder Zagaar, Associate Professor of Foundational Sciences, at Baylor College of Medicine, School of Medicine, Houston, Texas. They discussed their experiences with shortening the foundational sciences curriculum, curricular challenges and opportunities, and how they are addressing the incorporation of the foundational sciences using a spiral integration and focused exposure to basic science concepts.

Dr. Ismail began with discussing curricula trends by presenting AAMC data (Curriculum Reports) showing curricula changes in US medical schools since 2017: ~20% completed curricular changes, ~65% planned or are in process of implementation, and 15% have no plans for changes. AAMC further reports that the majority of curricula changes target the pre-clerkship (also referred to as “foundational sciences”) phase typically by shortening its length. Other efforts of curricula changes target the enhancement of clerkship coordination and use of simulation, and more emphasis on interprofessional education, competency based education, team-based learning, self-directed learning formats, and online instruction.

Dr. Ismail then emphasized that in the context of USMLE Step 1 exam changes, the goal of curricula change is not to cut foundation sciences content but to better integrate basic science content throughout the whole curriculum, emphasizing on foundational thinking in clinical relevance and providing application or action opportunities for foundational sciences. Citing an issue of the Journal of IAMSE (before it was renamed to Medical Science Educator) from 2010, Dr. Ismail reviewed the value and role of foundational sciences in medical school education. She discussed that foundational sciences serve as basis of critical thinking and clinical problem solving, they enable learners to understand normal homeostasis, its disruption and management, and they require a fund of knowledge to base hypothetical possibilities and take action. Dr. Ismail finished her part of the presentation with highlighting that the majority of medical practice is routine with cases based on pattern recognition, but expert physicians rely on the understanding of basic sciences for difficult cases and require a strong foundational science background in order to write and deviate from guidelines.

Dr. Rowley continued with discussing curricular challenges at Baylor College of Medicine. He stated that the first step to meaningful integration of foundational sciences is accountability. Baylor College of Medicine has a history of experimenting with curricular changes. In the 1970, they explored an optional 3-year program with a truncated basic science curriculum, yet ultimately settled on an 18-month foundational science phase in a 4-year overall medical school curriculum. One major challenge was the departmental accountability for curricular content as courses were directed by experts in different departments resulting in “siloed management”, e.g., biochemistry in the Department of Biochemistry, pharmacology in the Department of Pharmacology. In the late 1990, Baylor College of Medicine started to centralize oversight and thus accountability to curriculum deans and the curriculum committee, which was a first and necessary step to address meaningful integration. As an example, a long foundational course emerged covering a human biology approach in which different disciplines were integrated in one course. However, over time it became apparent that content accountability was still managed more in a siloed manner and thus a curricular shift took place, from the intended curriculum to an implemented curriculum. A key question emerged: How do we best get back to the purposeful design and implementation of an intentionally curriculum that appropriately integrates basic sciences and foundational principles in clinical medicine?

Dr. Rowley stated that, in 2018, Baylor College of Medicine embarked on an intentional curriculum renewal. Decisions were made to strategically incorporate foundational sciences throughout the 4 years by starting with the bulk of foundational content including their clinical relevance during the first 12 months followed by deliberate threading of foundational material into the clinical curriculum. To do so, they used the method of Understanding by Design. According to this backwards design framework, the team started with developing desired outcomes, then assessments, followed by generating course goals, followed by session objections. The goal of this curriculum renewal process is to align fully the intended curriculum with the implemented curriculum.

Dr. Zagaar continued with discussing cultural reset of expectations and biases that can often hinder the curriculum viability and explained how a shared framework was helpful in keeping everyone focused and on target. He explained the three major components of the Understanding by Design framework that are well suited for a competency-based (or outcome-focused) medical education program: 1) Start with the end in mind, 2) Assess for understanding, and 3) Design learning experiences to teach. This process, starting with outcomes and working backwards to develop appropriate assessment tools before curricular content, is the opposite of the typical forward design method in which content is determined first. A clear understanding at the beginning of the destination assures that the steps taken are always in the right direction and encourages deeper understanding of transferrable concepts or skills (enduring knowledge) as opposed to just covering facts.

Dr. Zagaar then explained how Baylor College of Medicine used the principles of the Understanding by Design framework to guide their curriculum renewal process while maintaining a shared focus. First, the team had to establish essential understandings that are basic to the practice of medicine, including foundational sciences, clinical skills, metacognitive awareness, and inquiry. Second, they had to clarify acceptable evidence of learning that embraces individual student challenges; specifically they pivoted from a traditional approach to assessment towards a multifaceted assessment that included qualitative and quantitative formative assessment with build-in remediation that encourages students to progress from competence towards excellence. Third, they developed an integration mechanism for tracking alignment of curriculum by using curricular threads that helped them moving away from siloed structures towards a system accountability for learners, faculty, and curricular administrates.

Dr. Zagaar then illustrated their integrated framework as a staircase representing foundational sciences structured across the curriculum incorporating metacognition, clinical reasoning, and inquiry. Transitioning into medical school starts with basic understanding and board exposures to the principals of health and disease. From there, the foundational sciences are introduced from molecular to psychosocial levels, anchored with metacognitive and clinical context and delivered using different learning methods like self-directed learning (“Why?”). Thereafter the students will progress to an integrated system based framework of applied sciences in which foundational knowledge will be applied to clinical actions (“How?”). Build-in remediation is meant to capture all students by providing support, time, and opportunities to progress towards the desired outcomes. In the last phase, foundational science knowledge and thinking skills continue to be reinforced by purposeful repetition through integrated teaching sessions and mentored experiences to apply foundational science towards the discovery of new knowledge and dissemination.

Using another diagram Dr. Zagaar demonstrated the mechanisms of their curricular threads. The foundational science and clinical sciences were shown as two opposing triangles, with an overlapping diamond through which the three main curricular thread families are intertwined: foundational sciences, metacognitive skills, and clinical preparation skills. These threads ensure flexible movement from understanding to reasoning to taking action, and provide an accountability system for outcomes, assessments, and instructional content. Such threading of instruction and assessment encourages foundational thinking. The connect can be delivered in individual steps: Hybrid case-based clinical scenarios, hybrid clinical encounters, simulation-based learning, clinical teaching integrative sessions, applied foundational science electives, and an inquiry project that deliberately tie in foundational sciences into clinical decision making. Dr. Zagaar then gives a specific example of how a pharmacology skillset could be achieved using this framework.

In conclusion, Dr. Zagaar listed the three take home points: 1) Changes to USMLE are an opportunity to innovate, 2) Foundational sciences are essential for clinical-reasoning and decision-making, and 3) The Understanding by Design framework is well suited for competency-based medical education.
The presentation lasted about 30 minutes. During the ensuing 30 min, an engaging discussion followed addressing a record number of >60 questions from the audience, including change management, faculty development, specific challenges, who and how many individuals were/are involved in the process, how were content domains identified, etc. Dr. Ismail, Dr. Rowley, and Dr. Zagaar answered live and responded via the Q&A Chat function.