Building research capacity for rural and regional medical students – University of Wollongong

Building research capacity for rural and regional medical students – University of Wollongong

In 2011, the of University of Wollongong’s medical school began replacing its conventional research training with a new approach of integrating research training into the MD degree, and offering students an authentic research experience while on their longitudinal clinical placements.  

Why was the program undertaken?  

An increasing international focus on building research capacity among medical practitioners [1–5], and the aspirations of the Australian Medical Council (AMC) to improve the research skills of graduating medical doctors [6], together highlight the need for medical schools to develop their students’ research skills. However, engaging medical students in developing their research and critical appraisal skills is universally regarded as a challenge.  

Many graduating doctors believe their knowledge of basic research skills is lacking and that they have limited experience with research [7,8]. Similarly, while the majority of the Australian specialist college research curricula (n=58) have a scholarly research requirement, only 11 of these require formal research training and only two require experienced research supervision [9]. 

The Research and Critical Analysis (RCA) program within the Medical program of the University of Wollongong (UOW) represents a departure from more conventional attempts to develop medical student research capacity in that it is integrated within the MD program and prepares students for an authentic research experience when on their longitudinal clinical placements. These approaches have been shown to promote a culture of research awareness in new graduates and can positively influence the development of a professional identity as a clinician researcher.  

The program is modelled on Boyer’s suggested four domains of academic scholarship: discovery, integration, engagement and the scholarship of teaching [10]. Students embrace the scholarship of discovery through their RCA lectures and assessment tasks, especially during the earlier phases of the MD program, and engage with their communities by undertaking research relevant to the community during the later phases. Boyer’s scholarship domains are also reflected in the integration of RCA learning outcomes into the MD program, and the subsequent integration of the students’ newly developed skills in research within the clinical and community settings of their placements, as they undertake their research projects. 

How was the program implemented?  

When first introduced in 2007, the UOW RCA program followed a traditional focus on statistical analysis as an example of research skill development. However, it received negative student feedback regarding this more traditional approach, providing the catalyst to revisit and redesign the program. As part of the redesign implemented in 2011, we embedded and integrated RCA throughout the four-year graduate-entry MD program. We also continued to seek student feedback, as well as detailed feedback from internal and external peer reviewers, helping to build coherence within the program. 

Rather than provide one-off or disconnected lectures and teaching of research methods, we anchored and integrated the RCA program within all four phases of the degree (Figure 1). The program is characterised by its alignment with medical sciences and the clinical curriculum, its longitudinal nature and the students’ progressive development of research skills – culminating in their capacity to undertake their own research project with and without supervision and mentoring.

Figure 1: UOW Graduate School of Medicine MD Curriculum 

Nine RCA learning outcomes (Table 1) were used to guide the development of the program, ensuring that RCA principles being taught during the early phases (Phases 1 and 2) were fully integrated with the scientific and clinical content. The later phases build on this by incorporating rigorous critical analysis and research experience, with students undertaking a supervised research project in Phase 3, and independent reflective and critical evaluation of evidence-based practice in the clinical environment in Phase 4.

Table 1: Research and Critical Analysis Program Learning Outcomes

The redesigned program aligns with the spiral curriculum structure of the MD program and includes assessment tasks throughout its duration, which are designed to demonstrate development of RCA knowledge, skills and attributes linked to the learning outcomes (Table 2).

Table 2: Research and Critical Analysis Knowledge, Skills and Attributes demonstrated by students across the four Phases of the UOW MD program

Miller’s pyramid [11] was used as a framework to demonstrate students’ progression through their research skill development, commencing as research novices in the earlier phases and becoming research competent in the later phases. The students’ research knowledge, skills and attributes, as outlined in Miller’s pyramid, could also be described as research competencies (Figure 2). Development of these research competencies leads to increased levels of research understanding, sophistication and proficiency, which contributes to the long-term goal of graduating research-aware doctors who can practise evidence-based medicine.

Figure 2: Miller’s pyramid illustration of how GSM Medical students progress through phases 1-4

Phase 1 (18 months, university-based) focuses on delivering content typical of the research paradigm, through lectures, Journal Club presentations, discussions and assessment tasks. Moving away from old-style statistical methods, students are taught skills in literature searching, critical analysis, interpreting statistics, research methods and evidence-based medicine.

The unique feature of delivery, which appeals to the students, is the way RCA principles are integrated with the scientific and clinical content of the particular body system block being taught. For example, students learn how to interpret systematic reviews and meta-analyses during the Cardiovascular and Respiratory block, discussing the scientific and clinical evidence around the use of statins for hypercholesterolemia and cardio-vascular mortality prevention, whilst learning the basic and clinical pharmacology of statin. Other examples include: teaching principles of screening specificity and sensitivity in the context of bowel cancer, and burden of disease in the context of diabetes. The interactive Journal Club, embraced by students, encourages teamwork and promotes presentation skills in a supportive environment, and further extends student learning within a framework of the clinical and medical sciences.

Phase 2 (12-months, hospital-based clinical placements) involves seven clinical rotations, during which students apply the knowledge gained in Phase 1 to critically appraise clinical practices relevant in a hospital setting. Here they identify the use of evidence-based guidelines, and lead and participate in clinical team Journal Clubs. In order to encourage further specific learning for individual students within the context of their speciality hospital rotations, students complete RCA assessment tasks which focus on the critical appraisal of drug advertisements and patient-oriented evidence that matters. This assessment choice has routinely inspired students to organise their own special interest groups to undertake additional study within specific clinical research areas.

Phase 3 (12-months, regional/rural community-based clinical placements) all students undertake a research project while on their 12-month clinical placement, culminating with a manuscript style project report and a conference style poster presentation. The research project aims to consolidate and expand on the research and critical appraisal skills introduced in earlier phases of the RCA program. The projects are supervised and mentored by UOW academics and clinicians, and supported by practical online research resources. The majority of the research projects relate to community issues and national health priority areas [12].

Phase 4 (six-months, advanced elective training and preparation for medical internship) involves students working independently to complete a case study or a professional practice reflection as part of the capstone assessment task, independent of research-academic supervision or mentoring. This is reported in a format suitable for submission to a journal and also as a conference-style oral presentation. This capstone project is a reflective and critical evaluation of evidence-based practice in the clinical environment.

What is the program achieving?

National Recognition of the RCA Program

The RCA program has attracted national and international interest, and received a Program Award for University Teaching from the Australian Awards for University Teaching (AAUT) in 2016, as well as an Australian Office of Learning and Teaching (OLT) citation award in 2015. The program surpasses the AMC curriculum standard – to encourage, prepare and support student engagement in medical research, by engaging individual students with all aspects of research throughout their entire medical course.

Improvement in student engagement and capacity for research

Student evaluations after the redesigned RCA program was first implemented in 2011 indicated strong agreement that their learning was being supported, that there were clear learning objectives and that they were overall satisfied with the RCA teaching program.

In addition, we have evidence that our RCA program has contributed to statistically significant increases in nine of the ten research areas highlighted in Figure 3 (below). The only research area which did not improve was applying for research funding, which is not taught as part of the program [13, 14].

Figure 3: Research experience scores of three consecutive medical student cohorts (n=221) pre and post completion of their Phase 3 research projects [13]

Positive Impact on Community Placements

As mentioned above, the majority of the research projects relate to community issues and national health priority areas. An audit of the topics of medical student research projects over a 10-year period indicated that 70% aligned with the Australian Institute of Health and Welfare priority areas [12] and approximately 20% focused exclusively on rural health-related topics. Engaging in health-related research projects while on regional and rural placements has raised the profile of our students in their placement communities and has, at times, resulted in the translation of research findings into practice (e.g. development of patient information resources; changes to GP prescribing practices; the increased up-take of interpreter services in a regional Emergency Department).

Research Capacity Building of Medical Graduates

Our RCA program has been successful in graduating medical students who are research aware and research competent, enhancing their capacity to undertake research of their own and to practice evidence-based medicine. To date, over 800 of our medical student research projects have been successfully completed, with at least 60 of them being published in peer-reviewed journals and presented at national/international conferences.

The program demonstrates the possibility of providing a meaningful and sustainable total research experience during medical school and a strong base for life-long learning and evidence-based medicine practice. It has also inspired a number of our graduates to pursue higher research degrees (PhDs and research Masters) in different fields, such as rehabilitation and palliative care. Other graduates have gone on to conduct research and publish papers based on their specialty training programs.

Goals for the future

With a view to fostering more clinician interest in research and achieving RCA program sustainability, we have forged strong links with university-wide research groups and external providers, including the Illawarra Shoalhaven Local Health District (ISLHD), the Australian Health Service Research Institute (AHSRI), the Centre for Health Research Illawarra Shoalhaven Population (CHRISP) and the Illawarra and Southern Practice-based research network (ISPRN). These collaborative partnerships will play a key role in the sustainability and continued success of the RCA program. We also anticipate that these partnerships will help to encourage research capacity building for clinicians external to the University, who may be new to research and would benefit from being mentored or supervised by experienced academics from the University.

Acknowledgements

We wish to acknowledge the contribution of RCA staff over the years: Professor Peter McLennan; Professor John Bushnell; Associate Professor Kathryn Weston; Dr Warren Rich; Dr Pippa Burns; Ms Shelley Crowther; Dr Susan Thomas; Dr Megan Kelly.

References

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[9] Stehlik P, Noble C, Brandenburg C, Fawzy P, Narouz I, Henry D, et al. How do trainee doctors learn about research? Content analysis of Australian specialist colleges’ intended research curricula. BMJ Open 2020;10(3). doi:10.1136/ bmjopen-2019-034962

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[12] Australian Institute of Health and Welfare. National health priority areas. aihw.gov.au/national-health-priority areas/ accessed 30 July 2021.

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[14] Weston KM, Mullan J, McLennan PL. Building research capacity through community-based projects. Med Educ. 2010; 44(5):496-497.

PDF of case studies available here: Research in the Medical Curriculum, Volume 1 – A window on innovation and good practice 2022