Medical School Stories

No single support strategy explains Newcastle University’s strength, over two decades, in attracting Aboriginal and Torres Strait Islander students to its medical program and supporting them through to graduation. It is a combination of strategies and, most importantly, people.

There are currently 76 Aboriginal and Torres Strait Islander students enrolled in Newcastle University’s Joint Medical Program with University of New England [1], which means that almost one in five of Australia’s Indigenous medical students are studying in this program – a leading position amongst Australia’s 22 medical schools.

“The first 100 Aboriginal and Torres Strait Islander medical students graduated from Newcastle over a period of about 20 years [2] but I think we’ll reach the second hundred within the next five years,” says Professor Peter O’Mara, Director of Newcastle University’s Thurru Indigenous Health Unit, School of Medicine and Public Health. “We have a really strong network and all of our current undergraduates have absolutely got what it takes to get through. The things that might stop them are things we can’t predict or prevent; we can only support them through it.”

Medicine is a demanding course for any student but can be especially challenging for Aboriginal and Torres Strait Islander students from communities which still endure the long-term negative impacts of colonisation and dispossession. Newcastle nurtures the strength and resilience developed by its Indigenous students despite these negative impacts.

For Peter O’Mara, the idea to study medicine only came to him when listening to a talk by a young Newcastle medical graduate, Sandra Eades, who later became Australia’s first Aboriginal Dean of Medicine. Becoming a doctor wasn’t something that was ever in Peter’s sights – or a probable outcome for a former Newcastle mines worker – until he heard Sandra speak. Decades later, Peter, like Sandra, has inspired many Aboriginal and Torres Strait Islander people to study medicine.

Building Critical Mass

Sustained recruitment is the first objective for any medical school seeking to graduate more Indigenous doctors. It builds a critical mass [3] of Indigenous students, who form an expanding network of peer support for each other and become role models for new students once they have launched their medical careers. Attracting a sustained critical mass of Indigenous students has been a fundamental part of Newcastle’s success over time.

Newcastle and New England’s Joint Medical Program approaches recruitment with a high Indigenous admissions target that is set well above parity [4] with Australia’s Indigenous population. It reserves up to 10 per cent of domestic medical student places (up to 17 places) each year for Aboriginal and Torres Strait Islander students, which is a strategic response to the very low proportion of Aboriginal and Torres Strait Island doctors in the national medical workforce. [5] Annual commencement numbers do not always reach 10 per cent and conversely, the target can be exceeded in a particular year, depending on the applicants.

Newcastle and New England each run a bridging program for Aboriginal and Torres Strait Islander people wanting to attend their university. This resonates with research showing the importance of culturally appropriate pre-entry programs for both recruitment and retention of Indigenous students. [6]

.
Each year the University of Newcastle’s Joint Medical Program reserves up to 10 per cent of domestic medical student places for Aboriginal and Torres Strait Islander students.
.

Targeted recruitment to the medical program is managed by the Thurru Indigenous Health Unit, whose staff travel around the state to engage with Aboriginal communities.

“The success of our program has been built on reputation and grown through word-of-mouth,” says Thurru doctor and academic John Towney. “We go out and talk to people face to face, and they see us and find out who we are. We are all from areas within or around the footprint of the medical program, so we’re travelling and meeting people on an equal level, we’re not waiting for people to come to us to look at the university. You can’t really sit on campus and engage with people who live 500 miles away.”

One strand of this decentralised approach is taking a one-week Indigenous admissions program to multiple locations across regional NSW for applicants wanting to ‘test run’ what it would be like to study medicine.  Another is relationship-building with a wide range of Aboriginal-run health and community organisations where Thurru places medical students studying the Aboriginal Health curriculum. This builds positive word-of-mouth about the medical program amongst the staff and clients of these Indigenous-run organisations.

Tough Admissions Process

Accompanying the Joint Medical Program’s high 10 per cent Indigenous recruitment target is an intensive, one-week program for admission through the Aboriginal and Torres Strait Islander entry pathway. Peter O’Mara believes this Miroma Bunbilla Program has been a critical success factor for Newcastle.

“When I started working here at the university I felt that we were setting people up for failure. There was an academic mark requirement and we had an interview process, and I felt that some people were being brought on board to the medical program when it wasn’t the right time in their lives or they didn’t have enough science behind them, these sorts of things,” he says.

“Whether it’s uncle, aunty, cousin or sister, whoever becomes a medical student, there’s quite an air of excitement in the community that one of our own is going to be a doctor. But if they get broken and go back feeling a failure, that is generalised to the rest of the community – ‘Oh that Western medicine, it’s not for us. We can’t do that university stuff’. What we’ve done to stop that cycle occurring is develop a program where there are a lot more hoops to jump through – it’s really hard to get in but if you do, the chances of getting through are really high.”

The year before Newcastle piloted the Miroma Bunbilla Program, 50 per cent of its Aboriginal and Torres Strait Islander medical student intake failed the first semester. In the year the pilot was introduced, only one student failed one subject at the end of first semester. “Things just changed dramatically,” Peter says.
..
The Miroma Bunbilla program is structured to give participants an insight into what studying medicine will be like, with tutorials and problem-based learning, and participants required to hit learning targets and complete all activities to qualify. It also has a cultural component, giving applicants the chance to connect with Indigenous patients.

In some cases a program participant will choose not to continue with their application for medicine. The Thurru team see this as a part of a successful recruitment strategy and support these applicants in developing an alternative study pathway.

Progressing through to Graduation

After recruitment, the next critical objective for medical schools is supporting Indigenous students to progress through to graduation. Commencement of Aboriginal and Torres Strait Islander students in Australian medical programs has grown in recent years to reflect population parity, but graduation levels have yet to catch up. [7] Targeted and strategic support is required to empower Aboriginal and Torres Strait Islander students to negotiate the additional challenges many face in studying medicine.

Within the culturally safe space of the Thurru Indigenous Health Unit is a hardworking  Indigenous team of eight full and part-time academic staff and one administrative staff. They spend a week with Aboriginal and Torres Strait Islander applicants for the Miroma Bunbilla program, then continue to provide academic and pastoral support to successful applicants from enrolment through to graduation. A good proportion of these staff are Newcastle medical graduates themselves, from areas across the footprint of the Joint Medical Program. Together they form the crucial ‘people’ component of the Newcastle success formula. The value of having a relatively large number of Indigenous academic staff, and the positive impact of these staff on Indigenous students, cannot be overestimated.

“Our students feel safe, with our support, to be pushed outside their comfort zone,” says Darren Nolan, lecturer and communications lead with Thurru. “I think that’s part of the reason we have higher retention and graduation rates. We will back students and support them when otherwise they might think, ‘this is just too hard for me’ or ‘I can’t do it’. We say, ‘we know you can do it; we’ll support you’.”

The motivation of Thurru staff to work long hours, travel around the state and push hard to get the students through to graduation comes from a determination to achieve better health outcomes for Aboriginal and Torres Strait Islander communities.

“The students are part of our community and we view them as an extension of our community,” says Karen Nicholls, a doctor and academic with Thurru. “Their getting through the course reflects on us and there’s a lot more at stake because if we don’t have the Indigenous doctors out there, we are not going to have the impact on the health system that we need to close the gap. Every single student that gets through has the potential to make such a huge difference.”
.

“When you treat an Indigenous patient and they have never come across an Indigenous doctor before, it is the most humbling and inspiring thing to experience – for both the patient and the doctor. There is nothing like it.”
.

Like most of the Thurru team, Karen could be making a more money elsewhere but chooses to work on expanding the Aboriginal and Torres Strait Islander health workforce: “When you treat an Indigenous patient and they have never come across an Indigenous doctor before, it is the most humbling and inspiring thing to experience – for both the patient and the doctor. There is nothing like it.”

Multiple Support Measures

Putting in place one or two isolated support measures – like a scholarship or Indigenous entry pathway – is not enough to nurture and retain all Indigenous students recruited to a medical program. The medical schools which graduate the highest number of Aboriginal and Torres Strait Islander students, like Newcastle, implement a spectrum of best practice measures [8] including: culturally appropriate recruitment and selection processes, orientation and pre-entry programs, a supportive and enabling school culture, Indigenous academics, mentoring and tutoring programs, flexible delivery of content, accessible Indigenous Student Support Centre; social and financial support, and ‘leaving the university door open’ for students who leave before graduation to return.

Peter O’Mara believes that leadership at university level has been another critical enabler at Newcastle: “I have seen a number of universities around the country that have good people there with lot of knowledge, but the leadership don’t listen to them and don’t act on their advice, and as a result they don’t get the outcomes. Our uni listens to what we have to say – whether it’s the Dean of Medicine or the Health Faculty; right up to Vice Chancellor level.”

Teaching Aboriginal Health

Thurru also runs the Joint Medical Program’s Aboriginal Health component, a six-week pathway open to all medical students in 4^th and 5^th year who elect to have an extra skillset in Aboriginal Health. Now in its third year, the Aboriginal Health pathway has more medical students wanting to take the course than it has places available, says Kirsty Jennings, the doctor and academic who manages the pathway.

“Rather than looking at a deficit discourse or data-based teaching, we’re trying to engage students with lived experience so that they develop empathy and understanding,” she says. “And it’s not just the medically-based Aboriginal Community Controlled Health Organisations (ACCHOs) that we engage with, we travel to rehab services, out of home care, cultural centres; I’ve had students delivering meals on wheels to COVID-positive patients.”
.

“We see the Aboriginal Health training we do in medical school and later on in the medical colleges really as a quality control mechanism. It helps graduate better doctors all round.”
.

“The community overall have been really positive in contributing to teaching medical students about how to work with our Aboriginal communities – giving them good feedback and experience. I also make sure the students understand the importance of giving something back,” she says.

Success Builds Success

Peter believes that the training provided through the Aboriginal Health pathway equips all graduates to become better doctors: “When students are trained to practice Aboriginal Health well, they become a better practitioner for everyone because Aboriginal Health is about trauma-informed care, whatever the patient group may be…We see the Aboriginal Health training we do in medical school and later on in the medical colleges really as a quality control mechanism. It helps graduate better doctors all round.”

If Peter’s predictions are correct, Newcastle’s Joint Medical Program will be graduating its 200^th Aboriginal and Torres Strait Islander doctor in 2027 – a great result in a country with such low numbers of Indigenous doctors in its national workforce. The simple but extremely powerful message that Peter and the other members of the Thurru team continue to spread as they travel to Aboriginal communities across NSW is, “If we can do it, maybe you can too”.

[1] 2022

[2] 105 Indigenous medical students had graduated from Newcastle Uni by 2022

[3] “A critical mass of eight students has been identified as the minimum number of enrolees at any one time likely to result in successful completion of studies.”  Meiklejohn B, Wollin JA, Cadet-James YL. Successful completion of the Bachelor of Nursing by Indigenous people. Australian Indigenous Health Bulletin. 2003;3(2).

[4] About 3.3 percent of Australians are Aboriginal and Torres Strait Islanders [Australian Bureau of Statistics].

[5] In 2020, 0.47 per cent of employed Australian medical practitioners identified as Aboriginal and Torres Strait Islander [Australian Government Department of Health], equivalent to 494 doctors.

[6] Beyond Enrolments, Emma V. Taylor, Alex Lalovic & Sandra C. Thompson. International Journal for Equity in Health, 2019. https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-019-1038-7

[7] In 2021, 3.2% of commencing domestic students, and 2.1% of domestic graduates, were Aboriginal and Torres Strait Islander people (2020_MDANZ-Student-Statistics-Report-1.pdf, medicaldeans.org.au).

[8] Emma V. Taylor, Alex Lalovic, Sandra C. Thompson, Beyond Enrolments, International Journal for Equity in Health, 2019.

Western Sydney University’s School of Medicine is a leader in graduating students – both Indigenous and non-Indigenous – with the skills and cultural proficiency to improve health outcomes for Aboriginal and Torres Strait Islander patients.

Western Sydney University (WSU) opened the doors of its medical program in 2007, preferencing applicants from Western Sydney to address a scarcity of doctors in the region. A second major driver was to grow the number of Indigenous doctors, given Western Sydney has the highest Aboriginal and Torres Strait Islander population in Australia.

“The whole course is underpinned by this model of social accountability, so the doctors trained here have a kind of ingrained understanding that they’re accountable to their community and society, and that being Western Sydney, it’s a relatively socially disadvantaged society,” says Paul Saunders, a doctor and Senior Academic with WSU School of Medicine. “We want to select students embedded in the community who will go back and be a doctor for that community.”

As a young Biripi man living and working on Dharawal land in Western Sydney, Paul was part of the very first cohort of WSU medical students in 2007. Now on staff, he has witnessed the level of support for Indigenous students rise from relatively little when he was studying, to the current wrap-around program which is empowering a growing number of Aboriginal medical students to graduate from Medicine.

Embedding Indigenous Health

The medical curriculum Paul teaches has Indigenous Health embedded across each year of the five-year degree.

“We develop the students’ knowledge of Indigenous cultures, then try to influence attitudinal change, which is the foundation for skills development – like how to communicate with an Indigenous person, understanding the resources available for you in the clinical setting, and being able to apply these skills in practice. That process takes five years. It’s not something you can do in the first year; it’s a transformational approach running across the whole course,” he says.
.

“You’re never going to be culturally proficient until you’re actually embedded within that community, seeing Aboriginal patients coming in the door and communicating and treating them.”
.

“Cultural immersion is a big factor. You’re never going to be culturally proficient until you’re actually embedded within that community, seeing Aboriginal patients coming in the door and communicating and treating them.”

WSU is in an enviably strong position to offer its medical students cultural immersion, due to the strong relationships it has built with Aboriginal Medical Services (AMSs) around NSW.

“It’s not as easy as just going out and saying, ‘Will you take on our students? There will be a fee in it for you’. It’s about building a relationship based on trust. A lot of Aboriginal communities have been approached about an arrangement or a deal and then been left in the lurch. That’s happened all too often. So now it’s about trust; about showing your face regularly and being cautious about promising too much,” Paul says.

The Dean of Medicine at WSU, Distinguished Professor Annemarie Hennessy, has worked hard over a decade to develop and maintain the school’s good relationships with AMSs. Working with her in the leadership team is Professor Aunty Kerrie Doyle, Associate Dean, Indigenous Health. Another key team member is Uncle Ian Kennedy, who has the complex job of managing the students on clinical placements in AMSs around the state and plays a major part in maintaining the good relationships which give WSU access to these organisations.
.

“It took three years to build the partnership with Broken Hill, and schools looking to forge similar partnerships with Aboriginal-controlled organisations should count on a similar lead time”
. 

WSU most recently partnered with the AMS in Broken Hill, which includes Wilcannia and three small AMSs near the border of NSW and South Australia, where WSU students fly in and out for clinical placements. It took three years to build the partnership with Broken Hill and schools looking to forge similar partnerships with Aboriginal-controlled organisations should count on a similar lead time, Aunty Kerrie says. To help convey lessons learned, she is writing a handbook documenting the team’s collective experience in building positive relationships with Aboriginal communities and organisations.

Graduating more Indigenous Doctors

The recruitment target at WSU is ten Indigenous students per year, within a total cohort of 130 to 140 commencing students. It was once difficult to recruit the ten, but Indigenous applications have grown to 20 to 30 per year and the target is now generally achievable.

“We start giving parents information about the medical course when their kids are in Year 6, and we run a FutureDoctors@email for people to let the school know they are thinking of doing medicine so we can keep our eye on them and get in touch once a year. We send some of our students into high schools to say, ‘Think about becoming a doctor; this is what you have to do’. It’s a big team effort,” Aunty Kerrie says.

When Annemarie recruited Aunty Kerrie to the position of Associate Dean, the medical program had a fairly high rate of attrition of Indigenous students in the early years of the degree. The wrap-around Indigenous student support program now overseen by Aunty Kerrie aims to minimise the life pressures many Indigenous students are dealing with, to allow them to focus more on their medical studies.

On the second day of each year’s Orientation Week, all Year One students in Medicine are taken to the Tharawal Aboriginal Corporation for a cultural immersion day where they meet some of the local Elders, learn some Indigenous knowledge and history of the surrounding Campbelltown area, and watch an Aboriginal performance.

“Right at the start, what that does for the Indigenous students is they get this feeling that their culture is accepted and valued within medicine. It’s like giving them permission to continue to be proud of their culture while they’re in the course and makes them feel more at ease,” she says.

The holistic support provided to Indigenous students by the school includes:

• Onboarding well before the students arrive.
• A tutor assigned to each student
• An Indigenous support centre close to the medical school, providing access to a kitchen, food, computers, textbooks and anything else students need to study effectively
• A weekly food hamper, recognising the financial constraints of many students
• In addition to the Puggy Hunter scholarship (available to all Indigenous students in a health discipline), a $7,500 housing scholarship available for those struggling to pay for accommodation or coming to university from a distant location
• Contact with Centrelink to ensure students receive the highest (Masters) level of Abstudy
• Encouraging students to apply for a $3,000 Summer scholarship in research
• Discouraging students from taking an external job while studying medicine.

Aunty Kerrie and Paul work from offices located about 15 metres from the Indigenous support unit their students use and less than 50 metres from the School of Medicine. They are highly accessible and encourage students to knock on their doors at any time.

“I announce at the beginning of every year: ‘We’re not happy if you’re hungry and we’re not happy if you’re homeless, so call me. We can sort anything’,” Aunty Kerrie says. “I think having that safety net there is a big help for a lot of our students. Some of them have come to the course without even a laptop.”

Both Aunty Kerrie and Annemarie are skilled at reeling in funds from multiple sources to cover the cost of additional resources – be it a computer a place to stay or tutoring. This ‘can-do’ attitude on the part of the leadership team makes a difference in a university environment where funding is tight.
.

“We really don’t lose any [students] now. We have had a couple fail due to an accident or illness but they’re not failing because they can’t do the work or because they’re not interested; they’re failing because of life events.”

.
.Attrition rates have dropped substantially since the support program was implemented: “We really don’t lose any [students] now. We have had a couple fail due to an accident or illness but they’re not failing because they can’t do the work or because they’re not interested; they’re failing because of life events,” Aunty Kerrie says.

 
Career Pathways

The variety of Indigenous medical specialists who have graduated from the WSU medical program is a point of pride for this relatively young medical school. These specialists include a Neurologist, an ED specialist, two Dermatologists and, very soon, the first Indigenous female Surgeon.

The WSU Indigenous Health team meet with the NSW Health and Education Institute (HETI) at least three times a year to support transition of Indigenous students from medical school. They discuss vocational training preferences with the students and provide information on what the different medical colleges are looking for and how to approach the interviews. They also encourage students to have least at least one publication as first author (e.g. in Journal of Public Health) by the time they graduate.

Paul believes that the most critical factor holding back the growth of Indigenous specialists is a lack of Indigenous leadership: “As with anything, you need to build Indigenous agency in whatever it is that you’re doing. If it’s the School of Medicine, you need to recruit Indigenous people – and not just level A, they need to be Indigenous leaders. We’ve got that with Aunty Kerrie. Annemarie recognised the need for that and we are now witnessing the impacts.”
.

“We want to graduate doctors with the generic attribute of being able to offer unconditional positive regard for Indigenous people.”
.

For Aunty Kerrie, the green shoots seeded by the program create the greatest joy: “I got a letter from this Aboriginal woman I know to thank me for teaching the students how to care for Aboriginal people. She was admitted to the Emergency Department at Wyong and said she’s never had a doctor before who really knew the questions to ask her. That was really heartening for us. We want to graduate doctors with the generic attribute of being able to offer unconditional positive regard for Indigenous people.”

The University of Otago is home to one of the most successful programs supporting Indigenous health workforce development in Australia and New Zealand. Over the past decade it has made a significant contribution to New Zealand reaching population parity [1] in the percentage of Māori doctors graduating from medical school.

Each year of the medical program at the University of Otago has its challenges but the first year of Health Sciences – a mandatory year for all aspiring medical students – has typically been the point of highest attrition for Māori students. So there was great interest in 2012 when the number of Māori students completing Health Sciences First Year and transitioning into medicine jumped dramatically – from an average of 18 students in previous years to 45 students.

There had been no change in the selection criteria for Māori entry to medicine that year. The catalyst for change was a support program developed by a small and passionate team at Otago’s newly created Māori Health Workforce Development Unit (MHWDU), with funding from the New Zealand Ministry of Health.

Since that time the Ministry has continued to fund MHWDU based on the continued success of its Indigenous support programs. The number of Māori medical graduates at Otago has risen steadily, reaching a high of 21.6 per cent Māori medical graduates in 2021 [2]  (61 of the total cohort of 287).

Targeted Support for Māori Students

Professor Joanne Baxter (Ngāi Tahu, Ngāti Mamoe, Waitaha, Ngāti Apa ki te Rā Tō), now Dean of the Dunedin School of Medicine, was one of only two people in the MHWDU team in its first couple of years. Zoe Bristowe (Ngapuhi, Ngāti Porou), Programme Manager with MHWDU, was the other.

“Before we had any targeted support for Health Sciences, Māori students were not doing well,” says Zoe. “We had the Māori Centre providing some academic support and offering a counselling service, but there was nothing targeted specifically to Health Sciences First Year, which had one of the highest attrition rates for Māori students at the university. The issue, of course, was what was happening in secondary school and not all students having the requisite sciences when they got here.”

The MHWDU team identified and recruited 14 Māori students for Tū Kahika, a new scholarship program to support students through a Foundation Year in 2010 – effectively a bridging program between secondary school and the highly competitive Health Sciences First Year common to all health professional programs at Otago. Rather than recruiting the ‘best’ Māori students from the ‘best’ schools – which would have done little to lift overall Indigenous numbers – the strategy was to identify potentially promising students from diverse backgrounds, including some who would not otherwise have been likely to go to university, and provide them with a scholarship, accommodation at an Otago residential college and wrap-around pastoral support during the Foundation Year.

Most of the 2010 Foundation Year scholarship students [3] were admitted to Health Sciences in 2011, where they met with other Māori students. MHWDU stretched its resources to embrace all Māori students in Health Sciences First Year – providing information, food, events and a lot of the team’s time. When the two Māori student groups coalesced, they lifted the collective performance of the Māori cohort in Health Sciences First Year to an unprecedented level, achieving a record 45 places in Otago’s 2012 medical program.

“In an environment that had some quite hostile cultural norms for Māori students we wereable to create a sheltered space around the students,” Zoe says. “We developed really good partnerships with the residential colleges and we would be invited up there for dinner, so we became just like an extended family, all with a similar goal. It was quite motivating for the Foundation students; for some of them it was the first time they had met another young Māori person who wanted to become a health professional. When they went into Health Sciences First Year, they pulled others into the fold.”

An Indigenous Led Model

The Foundation Year scholarship program continues to take an average of 13 to 16 students per year but is relatively costly and time-intensive given its small numbers. The greatest success has been in Health Sciences First Year, where admission rates for Māori students have consistently increased across medicine and nearly all other Otago health professional programs.

“We’ve done well because we’ve been able to implement an Indigenous-led model underpinned by Indigenous values. It’s about that sense of family and connection, and also collective success, which in a year that has always been really competitive can seem foreign. We all support each other so we can all progress together, and that’s been powerful.”

MHDWU currently has eight staff and is applying its proven Indigenous support model to the more recently introduced equity pathway into health professional programs for students from schools in low socio-economic communities (the EQ Project).

The Clinical Years

Otago students complete the first three years of the medicine program together at the Dunedin campus, then separate for three years of clinical training at one of three Otago medical schools, based at Dunedin, Christchurch and Wellington.

About 20 Māori students start clinical training at Christchurch each year and about 50 Māori students are at the Christchurch medical school at any one time. These students come under the orbit of Dr Tania Huria (Ngai Tahu / Ngati Mutunga Wharekauri),  Associate Dean Māori and more recently also Associate Dean Student Affairs, Christchurch, a role encompassing all undergraduate medical students across the three clinical years.

Tania’s team first meet the new Māori students coming to Christchurch when they take all new medical students away to a Marae [4] at the start of their first clinical year. The team then has ongoing contact with the Māori students moving forward, providing clear touchpoints within the faculty so that students know who to approach for information or to discuss an issue.

Tania also links the Indigenous students into the Māori Health Innovation Health Institute (MIHI), which runs OSCE practice at crunch times during the year and provides opportunities for students to meet Indigenous doctors working in the community. A Tuakana-Teina (senior-junior) Māori student support network, devised by students, runs a buddy system and schedules dinners and anti-racism/resiliency workshops.

“We don’t get everybody. It’s not a perfect program by any means. But we get most of our students on board at the beginning of the year,” Tania says.

More than 140 hours of the three-year curriculum are devoted to Māori Health, with an emphasis on simulations featuring community members acting out real cases and Māori doctors and other health professionals helping to facilitate the sessions. This practical component is expensive but extremely effective.

Cultural loading [5] on Indigenous students has been a pervasive problem but is beginning to diminish at Christchuch, Tania says. “We’re very clear that we want our Māori students to be students, so if we hear of any incident where they have been asked to be Māori experts – in a tutorial for example – we tell them to ask whoever it is to come and talk to us. This can be really insidious for both staff and the students, although it’s not happening as much now because we’re developing a bit of a critical mass. We do a lot of post graduate training in Māori Health so a lot of clinicians at the hospital have been through our training, which is quite helpful, and a lot of the junior RMOs are our graduates.”

Taking a Stance against Racism

While cultural safety for Māori health students at Otago has improved over time, racism and discrimination remain problems just as they do in the health workforce and society, Tania says. She references a legal case challenging Otago’s Mirror on Society medical admissions policy, which was settled out of court in 2020, and a recent review of the university’s Physical Education Department following complaints of racism toward the Māori unit within that department. In the wake of these events, Otago’s Vice Chancellor has taken a very vocal stance against racism and strongly endorsed the Mirror on Society policy.

“It all comes down to leadership. If a university or a medical school has leadership that supports and invests in equity then it’s great, but if the leadership isn’t prepared to acknowledge racism or inequity, that is an issue. It has to be a priority. It’s not acceptable that Australian and New Zealand Indigenous people continue to have the worst health and wellbeing outcomes.”

Two of the three Deans leading Otago’s medical schools are Māori –  Professor Suzanne Pitama, Dean and Head of Campus, Christchurch, and Professor Baxter at Dunedin. This is a proud achievement for these medical education experts but also an inspiring milestone along the path to achieving more equitable health outcomes for Indigenous New Zealanders.

[1] Māori people comprised an estimated 17.1 per cent of the national population in 2021 https://www.stats.govt.nz/

[2] Medical Council of New Zealand, Workforce Survey, 2021 https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/d9d2757aad/Workforce-Survey-Report-2021.pdf 

[3] All 14 students became eligible for admission to university, whereas half had not been eligible prior to the Foundation year.

[4] Māori meeting ground.

[5] Requests for Indigenous students to provide information about Indigenous cultures and related aspects of Indigenous health and wellbeing.

From its home in Far North Queensland, James Cook University is committed to improving the health of rural, remote, Indigenous and Tropical communities. Its focus on Indigenous health has been a drawcard for many of the Aboriginal and Torres Strait Islander students enrolling in its medical program.

At a ceremony held one or two days before formal graduation, each Aboriginal and Torres Strait Islander student graduating from medicine at James Cook University (JCU) presses their painted hand onto a canvas that hangs in the foyer of the College of Medicine and Dentistry in Townsville. The painting is a visual reminder of the growing Indigenous medical workforce they are about to join, and a validation of their hard work to get to this point.

“One of our Aboriginal students told me she’d had some hard times during the course but walking down that College hallway and seeing that painting with the handprints of all the people who had come before helped her to get through those tough times,” says Karen Knight, Senior Lecturer with the College of Medicine and Dentistry.

The Handprint Ceremony is also an opportunity for the families of the new Aboriginal and Torres Strait Islander graduates to meet and connect with one another, with other Indigenous graduates and with the academic staff and deans of JCU’s health disciplines in a more intimate context than the formal graduation ceremony. JCU’s Division of Tropical Health and Medicine fosters this kind of personal engagement with families and communities as a means of supporting Indigenous students as well as a potential pathway to recruitment.

JCU’s Indigenous Family

In 2021, there were 25 Aboriginal and Torres Strait Islander students enrolled in JCU’s six-year undergraduate medical degree. The school attracts Aboriginal and Torres Strait Islander applicants from across Queensland, over the border into NSW, sometimes Victoria and in a couple of instances, South Australia and Western Australia.

In each of the last four years, five to seven Aboriginal and Torres Strait Islander students have commenced medicine at JCU, which is a comparatively strong and sustained result [1]. However, the most critical challenge for the College, as for all medical schools, is to nurture and empower these students to progress through what for many may be a difficult and challenging journey to graduation.

All Indigenous medical students at JCU receive a modest annual scholarship which, while it is a help, is smaller than many other scholarships on offer and not a key recruitment strategy for the College.

 .
JCU’s pastoral care and family-oriented culture is at the heart of the university’s offer to Aboriginal and Torres Strait Islander students.

.
The central hub of what JCU refers to as its ‘Indigenous family’ is the Indigenous Education Research Centre (IERC), a newly built, well-appointed research centre and meeting place on the Townsville campus, which employs a large team of predominantly Indigenous staff who operate in both Townsville and Cairns, and have strong connections with Indigenous communities and families in the region.
..
JCU also benefits from running the specialist GP Training Program for a large portion of Queensland, which connects the university to a wide range of Aboriginal-controlled health services across the state, providing a network of pathways channelling positive word of mouth about studying medicine at JCU into Indigenous communities.

Preparing Students for University

At the secondary school level, an important recruitment channel is the innovative program of Summer and Winter schools run by the IERC to encourage Aboriginal and Torres Strait Islander secondary school students to apply for university. Winter School is held in the middle of the year for students in years 10 to 12, while the Summer School at year’s end is for Year 12 students only.

“The students come in for a week; they do an induction on things you need to know about university then more specific programs on the courses they’re interested in,” says Donald Whaleboat, a Senior Academic with the College of Medicine and Dentistry. “For medicine, we give them some insight into anatomy and physiology, working with patients, understanding the health care system and that sort of thing. We also test them throughout the workshop, so that we have information which can strengthen their application if they decide they want to do medicine.”

“The whole experience of coming to uni goes a long way toward getting Indigenous students engaged in the system. We’re talking about people who may not have had a family member come to uni so they don’t understand the way the system works, and coming to Summer or Winter School really gives them that sense of connection at an earlier age and something to work towards. When they arrive at university for the admissions process, they know the people who have delivered the content for the Summer or Winter school. They see a familiar face and it makes them feel a bit more comfortable when they do their interviews,” Donald says.

JCU’s Summer and Winter schools started just two years before COVID-19 brought them to a close but are back again in 2022. The IERC is gathering data to develop an evidence base for how this initiative is laying some of the building blocks for the success of Indigenous students at university.

Pathways to Equity

Indigenous applicants to medicine at JCU are able to choose whether to apply through the Indigenous pathway, the mainstream pathway or both. Many choose to apply through both pathways and are interviewed by both selection panels.

“It’s part of the philosophy of the College on equity and working with disadvantaged groups,” Karen says. “They can choose to participate in both.”

Breaking down the inaccurate perception that Indigenous students take the place of other, more suitable candidates is vitally important for medical schools in Australia and New Zealand. This perception is an obstacle for all those working to close the gap in health outcomes for Indigenous peoples by growing the very small number of Indigenous medical practitioners in the national health workforces of both countries [2]. It is also one of the examples of racism most frequently cited by Indigenous medical students in Australia and New Zealand.
. 

“If other students don’t get it at the start, they get it as they go through the program; they understand why there is a targeted [Indigenous] pathway.”
. 

“Indigenous students go through the same exams and assessment process as all the other students, and a lot of Indigenous students are coming through with extra challenges. We have a lot of mature age students in the course who have done other studies and who have to work and support families. They have to do all that on top of studying medicine.”

Linking Pastoral and Academic Support

The IERC is a welcoming space for Indigenous students to visit, during the day and in the evenings, to talk with Indigenous staff and meet other Indigenous students from disciplines across the university. The location of a centralised Indigenous support unit within a university – its proximity to the medical school – can have a big impact on how much busy medical students will visit and benefit from the services it provides. In earlier years there was a dedicated Indigenous support unit for the health programs at JCU but the trade-off for moving to the centralised IERC, located farther away from the College, was the volume of Indigenous staff and students working at and visiting the IERC, as well as the first-class study and recreation facilities located there.

Great care is taken to ensure that the Aboriginal Elders and other Indigenous staff at the IERC who provide pastoral care for Indigenous medical students work closely with the medical school staff who provide academic support at the College.

“Let’s say we have an Indigenous student who has some challenges, we’ll refer them to our medical academic support centre and they will make contact with the IERC to see if there is anything else we need to do, any gaps, in order to support a student,” Donald says. “The same happens if we don’t hear from a student. That student may be disengaged or remove themselves because they’re struggling a bit and they may not be as forward as others in asking for help – or know exactly what they need help with. We need to have our eye on the ball in regard to how they are travelling, so we look for the early warning signs and try to follow them up very quickly.”

Racism, Discrimination and Cultural Safety

An Indigenous student mentoring program linking senior students with those in the early years of medicine was recently introduced at the College. The senior students provide advice on how to navigate the later years of the medical degree to their younger peers and discuss career aspirations and potential career pathways, encouraging the juniors to think long-term about their medical career. This kind of peer support and mentoring can have a powerful positive impact on the confidence and resilience of Indigenous students if the school has a critical mass of Indigenous students to enable it.

The College supports and resources the mentoring program and encourages students to drive much of the discussion content for its events.

Dealing with racism and discrimination is a recurring discussion topic – like discussing whether something said in class can be considered racist or hearing from an Indigenous junior doctor who has come back to the school to talk about their experience of racism and discrimination in the workplace and how Indigenous students might prepare for that. This can be critical for students given the level of bullying, harassment and discrimination reportedly experienced by Indigenous junior doctors in the health workforce [3].

A commitment to diversity and zero tolerance for racism is woven through the culture and curriculum of the medical program and the College – in the professionalism stream within the medical curriculum, through the STAR Program (Stand Together Against Racism) and in first year orientation for all College students.
. .
“We introduce all our students to this thinking from first year and we have a couple of sessions on what to do if you are faced with racist behaviour or comments, so that if students see it, it’s not the first time they’ve thought about it and they have some skills in their toolbox,” Karen says. “We want all our students to back up our Indigenous students if ever they see racism occurring.”

Another aspect of cultural safety is ‘cultural loading’ – requests for Indigenous students to provide information about Indigenous cultures and related aspects of Indigenous health and wellbeing. Unless medical schools have sufficient expertise on staff to teach Indigenous Health, it is very likely that Indigenous students will experience various forms of cultural loading while studying medicine, adding an unwanted burden to their already busy lives.

Karen is very careful not to pressure any of her students to represent their culture as a whole in a class context: “If they want to share, that’s great, but we are careful not to put anyone on the spot.”

Both Karen and Donald acknowledge the difficulty of ensuring cultural safety for Indigenous students when racism is a society-wide problem: “We’re always thinking ‘Are we doing enough? How well are we integrating diversity? What more do we need to do to support our Indigenous students?’”

Medical schools need to be constantly asking themselves these questions – as JCU are – to welcome Aboriginal and Torres Strait Islander students to their program and support them through to graduation. Building a culturally safe environment remains a substantial challenge for medical schools in Australia and New Zealand, but is a core aspect to contributing to equitable health outcomes by graduating more Indigenous doctors.

[1] A total of 207 students commenced the JCU medical program in 2021.

[2] 0.47 per cent of employed medical practitioners identified as Aboriginal and Torres Strait Islanders in 2020. [Australian Government Department of Health], compared with 3.3 per cent of the national population [ABS]; 3.5 per cent of medical practitioners identified as Māori [2019 Medical Council of New Zealand], compared with 16.7 per cent national population [2020 NZ stats, NZ Government].

[3] Results of Ahpra’s 2021 Medical Training Survey show that 52% of Aboriginal and Torres Strait Islander trainees reported experiencing and/or witnessing bullying, harassment and/or discrimination (compared with 35% of trainees nationally), and of those experiencing bullying, harassment and or discrimination, 49% reported a moderate or major impact on their training (compared with 38% nationally).

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

[1] van Weel C, Rosser WW. Improving health care globally: a critical review of the necessity of family medicine research and recommendations to build research capacity. Ann Fam Med. 2004 May 26;2 Suppl 2(Suppl 2):S5-16. doi: 10.1370/afm.194.

[2] Eley DS. The clinician-scientist track: an approach addressing Australia’s need for a pathway to train its future clinical academic workforce. BMC Med Educ. 2018;18,227. doi:10.1186/s12909-018-1337-5

[3] Modrek AS, Tanese N, Placantonakis DG, Sulman EP, Rivera R Jr, Du KL, et al. Breaking tradition to bridge bench and bedside: accelerating the MD-PhD-residency pathway. Acad Med. 2021;96(4):518-521. doi: 10.1097/ACM.0000000000003920.

[4] Andriole DA, Wolfson RK. The physician-investigator workforce: Looking ahead. Acad Med. 2021 Apr 1;96(4):486-489. doi: 10.1097/ACM.0000000000003944.

[5] Roberts LW. Going extraordinary distances with physician-scientists. Acad Med. 2021; 96(4):477-478. doi: 10.1097/ACM.0000000000003923

[6] Australian Medical Council. Standards for assessment and accreditation of primary medical programs by the Australian Medical Council 2012; AMC Limited. https://www.amc.org.au/wp-content/uploads/2019/10/Standards-for-Assessment-and-Accreditation-of-Primary-Medical-Programs-by-the-Australian-Medical-Council-2012.pdf

[7] Saeed I, Khan NF, Bari A, Khan RA. Factors contributing to the lack of interest in research activities among postgraduate medical students. Pak J Med Sci. 2018;34(4):913-917. doi: https://doi.org/10.12669/pjms.344.15411

[8] Muhandiramge J, Vu T, Wallace MJ, Segelov E. The experiences, attitudes and understanding of research amongst medical students at an Australian medical school. BMC Med Educ. 2021;21(1):267. doi: 10.1186/s12909-021-02713-9.

[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

[10] Boyer EL. Scholarship Reconsidered. 1990, Princeton, NJ: Carnegie Foundation for the Advancement of Teaching.

[11] Miller G.E, The assessment of clinical skills/competence/performance. Acad Med. 1990; 65(9)S63-67.

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

[13] Mullan JR, Weston KM, Rich W, McLennan PL. Investigating the impact of a research-based integrated curriculum on self-perceived research experiences of medical students in community placements: a pre- and post-test analysis of three student cohorts. BMC Med Educ. 2014;14:161.

[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

Prior to introducing its new research framework in 2020, the University of Sydney Medical School taught evidence-based medicine as a one-week intensive program in Year 1. Its new research framework uses clinical integration of research training, and a student–centred, team-based approach, to maximise student competency. 

Why was the program undertaken?  

Prior to introducing its new research framework in 2020, the University of Sydney Medical School taught evidence-based medicine (EBM) as a one-week intensive program scheduled late in Year 1. Content was delivered through mandatory face-to-face lectures and small group practical workshops. However, feedback suggested that students could not engage with the large amount of content delivered in traditional lectures and, while the critical appraisal workshops were well received, students had not retained content from the lectures and were not ready to apply it. Many students reported that they did not see the practical and clinical relevance of EBM. 

EBM and research methods are core components in medical education curricula globally. Best methods for effective teaching of EBM have not been definitively determined, however two key strategies have emerged for optimising curriculum delivery. First, clinical integration of EBM teaching is likely to bring about changes in student skills, attitudes and behaviour [1]. Second, blended interactive approaches, when compared with traditional didactic methods, have been shown to be more effective in improving student attitudes towards, and increasing self-reported use of, EBM in clinical practice [2]. Additionally, the blended learning approach has associated efficiencies, such as freeing up in-class time for student participation in active learning, and cost-effectiveness of delivery, which leads to improved value for institutions with repeated iterations [3].  

Team-based learning (TBL) has gained popularity in medical education [4], in line with the expansion of student-centred learning strategies, including flipped learning approaches and peer-assisted learning. TBL uses active, collaborative learning strategies to provide an authentic experience of approaching a clinical problem. TBL classes have been shown to provide an enhanced learning environment where students can build on basic knowledge and apply what has been learnt [5, 6]. The classic TBL framework is illustrated in Figure 1. [5] 

Figure 1: TBL framework 

In 2020, The University of Sydney Medical School launched a new curriculum and course structure for its four-year graduate MD program, with Research, Evidence and Informatics established as a vertical theme. The aims of the revised EBM curriculum were to ensure student competency in EBM learning outcomes, emphasise the clinical relevance of EBM, and improve student engagement and application of EBM teaching. The new program shifted EBM teaching from didactic face-to-face lectures to interactive, student-centred and clinically integrated modules.  

We used a modified TBL framework to develop Rapid Evidence for Practice (REP) modules that would provide students with EBM knowledge and skills, and prepare them to apply evidence within short timeframes – simulating real world clinical contexts. 

How was the program implemented?  

In the revised curriculum, EBM teaching is integrated into the Back to Basics (B2B) block, a nine-week term in Year 2, which introduces students to a range of clinical specialties, from paediatrics to aged care, following the human lifespan. This formal coursework program also provides foundational knowledge of research methods prior to students undertaking projects in a dedicated 14-week MD Research Project Block in Year 3.  

EBM content is informed by the Australian Medical Council (AMC) guidelines and a set of core competencies developed for health professionals [7]. The course design allows for a rapid change to online only format, if necessary, due to the uncertainty created by the Covid-19 pandemic regarding face-to-face teaching options. A logic model is used as a guide in developing, implementing and evaluating REP modules (Table 1).  

Table 1: REP modules Logic Model 

Four REP modules were developed, with each module focussing on a specific EBM study design in the following sequence: Randomised Controlled Trials, Systematic Reviews, Observational studies, Diagnostic Test Evaluations. An REP module development guide was created for each module (see Appendix, Table 2), detailing learning objectives, content suggestions, activities and assessment tasks, and ensuring consistency in structure.  

The REP module structure (Figure 2) comprises online informational content, an individual readiness quiz, a forum featuring a guided critical appraisal, and a student team-based rapid appraisal and application of a published article to a clinical scenario.  

Based on our previous experience of students not recognising the clinical importance of EBM and requiring considerable additional support to complete application tasks, we expanded the readiness assurance phase of REP modules to include an additional live forum. The forum features a panel session with real world clinician researcher experiences, a guided critical appraisal task led by our teaching team, and an opportunity for questions and discussion providing students with targeted appropriate knowledge and skills to apply in the subsequent REP activity.  

Figure 2: REP module structure 

In REP activities, students are given a clinical scenario and a relevant journal article, and they work through a series of questions with facilitator clarification of challenging questions. A summary of the session is then provided to the cohort. After the REP activity, students finalise and submit as a team a Decision Map (see Appendix, Figure 3), which illustrates how evidence, clinical knowledge and patient values intersect. General feedback on the Decision Map is provided to the cohort and direct feedback is provided to teams if a rubric element does not meet the expected standard. 

What is the program achieving?  

Evaluation methods 

In May 2021, Year 2 medical students completed a REP module on randomised controlled trials (RCTs). A mixed methods approach to evaluation included:  

1. Curriculum document analysis to assess content coverage of core EBM competencies. 
2. Student acceptance assessed using a questionnaire distributed immediately following the REP activity.  
3. Review of student participation and task completion using learning management system analytics (see Appendix).  

Document review  

Online videos, forum critical appraisal PowerPoint presentations and REP activity tasks were reviewed to determine the extent of their alignment with learning objectives specific to the RCT module and EBM competencies. The document review indicated that learning objectives specific to the RCT module were covered adequately. EBM competencies – including asking a focussed clinical question, applying the PICO framework to research questions, critical appraisal of a journal article and the application of research results to a clinical problem – were met. While acquiring appropriate evidence could be included within the REP module framework, we did not do so, due to time allocation constraints within the Back to Basics Block. Students have a separate lecture and access to library modules on literature searching.  

Student experience of the REP module.  

In total, 55/258 (21%) of participants completed the post-module questionnaire. Student responses to closed items regarding their experience of REP modules are presented in Figure 3 (see Appendix). The overall response was positive, with 81% of students agreeing or strongly agreeing that they were satisfied with this method of teaching. Responses to items 1–2 indicate that the preparation stage worked well, with 91% agreeing that short online videos were their preferred method of acquiring basic knowledge and 83% completing the pre-readings. Responses to items related to the readiness assurance phase were similarly positive, with 79% agreeing that the RQ improved understanding of concepts and 83% agreeing that the critical appraisal walk-through prepared them for the REP activity. Notably, 91% of students agreed that REP helped them develop a way to use evidence to approach clinical questions. 

Students’ responses to open-ended questions are illustrated in Table 3 (what students valued) and Table 4 (what could be improved) in the Appendix. Students valued the overall structure of REP modules due to the staged transition from knowledge acquisition to practice to application: “The stepwise approach to learning. The process has been very methodical and logical”. In addition, each component was valued for its role in the process. Short online videos were perceived as an effective method of delivering basic content: “The online videos are really good, easy to listen to and understand and not too long. They give a really good foundation of concepts that get reiterated in the activities”. The readiness assurance phase was valued as a practice task and REP activities were valued as real-life simulations: “It is good to have the chance to appraise an article and put the theory into practice in a manner very similar to how it would be in real life.” In addition, REP modules were perceived by students as being useful for their future career: “Very useful for me as I engage in the latter years of my training.”  

Suggested improvements included avoidance of repetition of basic content in the readiness assurance phase and changes to the clinician researcher presentations, which some students did not perceive as relevant: “The lectures with research examples do not benefit my learning. I feel like the information they give only apply to that one research project and nothing else”. Students also suggested expanded Q&A sessions, more practice activities, shorter duration of classes (two hours) and avoidance of replication of administrative tasks. 

Task completion  

All student groups submitted their Decision Maps and only one student from the cohort of 258 did not complete the RQ. 

Discussion 

We evaluated the REP module on RCTs embedded in Year 2 based on content, student participation and acceptance. Students found the TBL structure effective for their learning, enabling application of new knowledge to clinically relevant problems that may be encountered in their future careers. Student participation in the RCT REP module activities was high, with 100% completion of the outcome assessments.  

Some challenges we faced related to the introduction of a new teaching intervention, including the need for clarity regarding new terminology and scheduling of tasks. A welcome video explaining REP modules was created, all activities were included in students’ calendars and the assessment page detailed a timetable for the release of learning materials and due dates. There was some duplication of administrative tasks for students, which will be improved. Staff found it challenging to identify journal articles of an appropriate difficulty level for medical students that allowed them to focus on appraisal and application of EBM concepts and skills. Students have different levels of prior experience in critical appraisal, suggesting the need for additional targeted training in future iterations.   

The REP framework has successfully shifted our EBM and research methods teaching from didactic face-to-face lectures to interactive and clinically integrated modules. Students build on basic knowledge with practice activities and gain real-world experience in the rapid appraisal and application of EBM to clinical problems. The REP activity is an authentic task which promotes student collaboration, reflection and communication, with support from expert input. It provides students with the experience of small group learning in a large group setting, reducing the number of teaching sessions and facilitators required. In addition, REP modules can be run completely online, which provided a safeguard during the Covid-19 pandemic. 

References

[1] Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidenced-based medicine. BMC Medical Education. 2006;6(1):59.

[2] Ilic D, Nordin RB, Glasziou P,et al. A randomised controlled trial of a blended learning education intervention for teaching evidence-based medicine. BMC Med Educ. 2015;15:39. 

[3] Maloney S, Nicklen P, Rivers G, et al. A Cost-Effectiveness Analysis of Blended Versus Face-to-Face Delivery of EBMto Medical Students. J Med Internet Res. 2015;17(7):e182. 

[4] Burgess AW, McGregor DM, Mellis CM. Applying established guidelines to team-based learning programs in medical schools: a systematic review. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(4):678-88.

[5] Burgess A, Bleasel J, Haq I, et al. Team-based learning (TBL) in the medical curriculum: better than PBL? BMC Med Educ. 2017;17(1):243.

[6] Burgess A, Haq I, Bleasel J, et al. Team-based learning (TBL): a community of practice. BMC Med Educ. 2019;19(1):369.

[7] Albarqouni L, Hoffmann T, Straus S, et al.Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey. JAMA netw. 2018;1(2):e180281. 

APPENDIX 

Table 2: RCT Module development guide 

Figure 3: Decision Map outline

Figure 4: Student experience of the REP module

Table 3: Valued aspects of REP modules

Table 4: Improvements suggested by students for REP modules.

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

Notre Dame Fremantle’s Research Training Pathway  is a spiralling curriculum that engages students from week one and is integrated throughout the degree. Its goal is for all medical students to understand the research process, from inspiration to publication, and to possess the skills needed for critical review of research outputs as a future clinician. 

Why was the program undertaken? 

In 2016 the University of Notre Dame Australia (UNDA) School of Medicine Fremantle undertook curriculum development to align the MBBS degree (Australian Quality Framework level 7 program) with the competencies required of an MD degree (Australian Quality Framework level 9E program) as well as AMC accreditation guidelines. In particular, the curriculum required additional content specific to training clinical scientists. A research training pathway was created to complement the existing curriculum, focussing on evidence-based practice and principles of epidemiology.  

The Research Training Pathway is a spiralling curriculum covering all four years of the MD. It engages students from week one and requires them to undertake research training activities throughout the degree (see Figure 1, below).  Learning is iterative and each assessment forms part of an overarching, continuous learning portfolio across all domains in the MD. 

In first, second and fourth years, assessments in the Research Training Pathway are graded and constitute a small but significant part of each student’s final grade for their year-long unit. In third year, students are enrolled in a separate unit: Systematic Research Inquiry. There are three graded assessments within this unit contributing to an overall ‘non-graded pass’, with the unit being a pre-requisite to progress to the final year of the MD.

The general aim of the Research Training Pathway is to ensure that all medical students understand the research process, from inspiration to publication, and possess sufficient skills for critical review of research outputs as a future clinician.

How was the program implemented?

All Research Training Pathway activities have been designed within an experiential learning paradigm and follow a backward learning design where the final outcome drives the learning objectives along the pathway. The activities are built on the principles of cognitive theory for skill acquisition, articulated and applied by Neil Mehta as “educational mantras” (personal communication Harvard Macy Foundation, 2018). The mantras state that: deep learning occurs when students do the work; frameworks built at the right level allow discussion of exceptions; more time should be spent on conceptual knowledge; a variety of activities help to build conceptual frameworks; students may not know what they don’t know, and assessments are for learning not of learning. In addition, it is important that learning tasks involve a manageable level of intrinsic load, where extraneous cognitive load is reduced so that generative load is fostered and dual coding is promoted.

In the Research Training Pathway, scaffolded learning activities provide opportunities for students to create knowledge through critical review of scientific literature, through the completion of a detailed template, by planning a blue-sky research project and, finally, by applying their knowledge in carrying out a research project from inspiration to publication. There are no lectures; students acquire information implicitly as they engage in the material. Each activity in the first three years of their research training pathway is completed in small groups.  Each of the 12 groups per year is facilitated by a PhD-qualified and research-experienced tutor.

Tutors are paid on a sessional basis, thereby reducing the overall cost to the school, and many choose to work with students in all stages of the pathway. A framework has been developed to guide learning and ensure that all students have access to the same learning opportunities. Tutors are provided with detailed handbooks and attend briefing sessions prior to each activity/tutorial, for quality assurance. Students are also provided with a handbook and each activity is supplemented with bespoke learning resources.

The details of the learning activities included in the Research Training Pathway are as follows:

Activity 1: WikiMedicine Project – six hours in orientation week.

First year students learn to edit WikiProject Medicine pages as a vehicle to introduce them to the concepts of scientific writing, copyright, primary/secondary/tertiary sources of evidence, and the power of accessible information for education and self-care. This activity takes approximately six hours and utilises the online tutorials available on Wikipedia. Groups of three students work together to make three to four edits to a self-selected Wikiproject medicine page by the end of their orientation week (Week 1). At the commencement of semester two, the students review the status of their edits and present the statistical data reflecting: number of views, whether their edits were removed or changed, if the quality status of the WikiProject Medicine page had changed and if there had been any relevant discussion on the chat page related to their edits.

Activity 2: Journal article review (JAR) – six 90-minute online tutorials preceded by a 60-minute tutor briefing.

The journal article review activity involves peer learning in a small group context. Nine novel journal articles are chosen each year in accordance with several criteria – including relevance to the Problem Based Learning (PBL) topic being undertaken at the time of the tutorial and the type of research design and population involved in the research – to ensure that all students are exposed to a range of topics, design and analysis techniques.

Each student in a group of nine selects one of the available articles. That student is then required to read, review and present the essence of that article to their tutorial peers, through a five-minute presentation with a one-slide overview and a number of questions for class discussion. Students then engage their peers in the discussion of these questions/issues, typically covering aspects of the paper that they are struggling to understand. Each tutorial group uses breakout rooms on Zoom so that subgroups of two or three students can discuss each question for 10-15 minutes. The main group then provides further input to the lead student to assist them in completing their template. Each template is assessed summatively. Each student submission for a specific paper (one from each of twelve groups) is graded by a single tutor to ensure equity and to be on the alert for plagiarism.

The template requires that students engage in the publication process, methods of evaluating journal and author performance, research design, aims/research questions, hypotheses, methods, analysis and conclusions. It is a chance to ensure that all students acquire the basic information but also provides other more experienced students with opportunities to fill gaps in their knowledge. The template looks deceptively easy, however it provides a strong structure for learning and is a complex undertaking in that it needs to apply equally to a diverse range of research papers.

Activity 3: Journal article review (JAR) – six 90-minute online tutorials preceded by a 60-minute tutor briefing

In second year, students once again engage in a format nearly identical to that of 1^st year, with the exception that the questions in the second-year journal article review template require students to engage in higher-order thinking. They are required to make inferences, critically evaluate, compare and contrast research designs, comment on ethical implications and suggest alternative strategies.

Activity 4: Systematic research Inquiry – one orientation tutorial, six 120-minute tutorials and a tutor training session. All sessions are conducted online.

In third year, all students are enrolled in a separate unit: Systematic Research Inquiry.  Students work in groups of 10 and are able to sign up to a tutor-led group, based on availability, tutor research background and student preference: tutors post a summary of their areas of interest and expertise and, via a preference system, students can select who they wish to work with.

This unit is pass/fail in nature but involves three graded assessments. Students are required to develop a blue-sky grant proposal (assessment one) and submit it on an abbreviated National Health & Medical Research Council grant template. This template requires students to develop a budget, timeline and description of the personnel required, in addition to a project research design. Students are introduced to the concept of fields of research codes (FOR); in addition, they review ethical implications of their research via the completion of the UNDA HREC ethics application, including participant information sheet, data management and consent form (assessment two). These activities are for experience only and are NOT submitted to the university HREC committee for formal review. Finally, students are required to submit a three-minute video pitch of their grant proposal (assessment three).

Activity 5: Final year research project. Approximately 140 hours.

Students interested in undertaking a research project in their final year of the MD submit a research feasibility template towards the end of Year 3. The feasibility template requires students to report details such as the names of the supervisor/s, the project aims and methods, commentary on data availability and the presence of ethics approvals. They also need to report the type of support they may need to complete the project, noting the gap between their current skills and the requirements of the project. The template provides an opportunity for the research academics to assist students in refining projects so that they can be completed within the time allocation of 140 hours and to minimise any other risks that could lead to non-completion. The responsibility for the provision, organisation and management of projects is consciously placed with the student, to provide them with opportunities to refine higher-level professional skills.

Final approval for projects depends on research merit and completion, and is provided within the first weeks of the student’s final year. Students submit their completed research project in the form of a draft research paper for a selected journal of their choice. They are required to follow the detailed instructions for authors specific to the selected journal and are marked against a rubric including measures for adherence to publication guidelines, scientific communication, research design analysis and interpretation. Each student works with a supervisory team, including an academic employed by the School of Medicine as well as community based clinical scientists who provide the research data. Approximately 12 per cent of students elect to undertake a research project; the remainder undertake a clinical audit sharing a number of attributes with the research project option (i.e. meeting AMC requirements), but run by the Population and Preventative Health domain.

What is the program achieving?

There are two main advantages of the integrated Research Training Pathway: the first and most important involves student learning; the second is also important and involves ongoing education and upskilling for research stream tutors, many of whom undertake other duties within the school.

Firstly, all students have the opportunity to develop an understanding of scientific language and the research process in both a theoretical and applied way. Students who enter the MD with a research qualification report that their research knowledge has been enhanced and broadened. For example, many students say they previously had no understanding of qualitative methods or the financial implications of submitting an article to an open access journal. In completing the templates in first and second year, students become more confident in their ability to critically evaluate the author’s aims against the methods and analysis employed – an area that students frequently report feeling the least confident in. They also gain experience in summarising research involving a variety of research designs for their peers. Graduating students realise that “doing research” and “getting a publication” involves more than simply enthusiasm. The assessments provide them with a detailed overview of the skill sets required to undertake successful research and highlight any gaps they might need to address.

The second advantage of the program involves the professional development and teamwork experienced in the tutor briefings. Most of the tutors have remained in the program since its inception. They enjoy the ability to discuss papers with their colleagues and to share their research skills with students in small groups. In essence being a tutor in the Research Training Pathway provides ongoing professional development in current medical literature and a range of research designs and analysis techniques. The tutors bring with them a range of professional research skills and research backgrounds, including journal editors, experience in qualitative design and laboratory research, making for a rich and informative briefing session in which everyone gains skills.

WSU Medical School’s research training program is founded on an unswerving commitment to support the school’s social accountability mission through community partnerships. Its mandatory Community Research course component has both research and community engagement learning outcomes. 

Why was the program undertaken? 

In 2007, the then University of Western Sydney School of Medicine opened its doors to the first intake of undergraduate medical students, galvanised by a mission to meet the health and workforce needs of Greater Western Sydney (GWS). One of the most diverse, geographically dispersed and fastest growing outer metropolitan regions in Australia, GWS encompasses communities affected by significant disadvantage as well as some of the most highly-educated residents and high-income suburbs of Sydney, and the largest urban Aboriginal population nationally.  

In 2010, the first cohort undertook the Community Medicine Group Project during Year 4 of their five-year Bachelor of Medicine and Surgery (MBBS) degree, which by then had expanded to include rural North Coast and Western NSW. In 2012, this mandatory research course component was renamed the Community Research (CR) program to better reflect its dual research and community engagement learning outcomes (see Figure 1) and equivalence to clinical placements.  

In 2019, the MBBS was replaced by the Doctor of Medicine (MD) but the essentials of CR have continued as the MD Project: to learn research and scholarship by doing it, through interconnected teaching, research and service activities. The program’s evolution and sustainability are founded on an unswerving commitment to evidencing the school’s social accountability mission through community partnerships (see Figure 2), alignment with WSU research strategy, and research-informed curriculum design and implementation. 

Figure 1: Community Research Learning Outcomes 

Figure 2: The North Coast Medical Education Collaboration (NCMEC) 

The WSU Medicine teaching philosophy of experiential learning is reflected in the CR program; while research principles and skills can be acquired through theoretical knowledge and evidence-based medicine critical appraisal exercises, this learning does not become “real” until students conduct research, experiencing its limits as well as the satisfaction of findings that are immediately relevant (see Figure 3). For example, collecting and analysing data, whether from medical records, community interviews or surveys, becomes authentic and effective learning about the impact of well-designed data collection on data quality – and thus the validity and reliability of research findings. 

Figure 3: Community Research experiential learning pedagogy 

How was the program implemented?

The CR program is delivered to all WSU medical students (about 130 per year cohort), who work in groups of three to five, supported by allocated time in a four-week block in urban sites and sequential allocation over a year-long placement in rural sites. Scaffolding is provided in Years 1, 2 and 3 by aligning CR and graduate learning outcomes and assessments with Population Health and EBM teaching in lectures, small group workshops and online modules.

During Year 3, students select from an endorsed list of projects and supervisors, submit an assessable project plan and literature review, and obtain relevant ethical approvals. Students are thus prepared and ready to conduct data collection on the first day of their Year 4 CR placement. Supported by data analysis and report writing workshops and training tailored to the project’s study design, each group completes their project and submits a 4,000-word final report in the format of a research paper. CR study designs have included quantitative surveys, qualitative interviews and focus groups, medical record reviews and audits, systematic reviews, sub-projects within community-based randomised controlled trials, and novel approaches such as geospatial mapping. All assessments are threshold, and the final report is graded by experienced supervisors and the CR teaching team for anchoring and calibration.

The CR teaching team is founded on a strong collaborative culture and participatory practice, garnering university teaching awards for the strength of its collegiality and teamwork (see Figure 4). The team comprises the program convenor and two rural coordinators, with contributions from cognisant disciplines; team members possess strong expertise in qualitative, quantitative and mixed-methods research, and all are active and community-engaged researchers – we do and teach – with CR teaching being one of their many roles.

To inspire emerging clinician researchers, WSU students and alumni have joined the team as peer teachers and role models. Team teaching is particularly important for comparable learning experiences and assessment in a state-wide distributed program.

Figure 4: Recognition of Community Research Teaching Excellence

“Doing what we teach” is reinforced by a scholarly approach to CR teaching through: reflection on teaching practice and continuous evaluation (e.g. WSU Medical Alumni Survey findings have been used to enhance and re-sequence Year 1-3 scaffolding, with subsequent improvements in student satisfaction measures); using and producing educational research; benchmarking.

WSU has initiated collaborative projects with research teachers in other medical schools, leading to publications and findings that have been implemented in the CR program, including supervisor knowledge of research ethics (with University of Wollongong), motivating students to do research (with Sydney University), and compulsory research components (with Melbourne Medical School) (see Figure 5).

Since 2019, regular meetings of a WSU-initiated network of research program leads, which now includes Sydney, Wollongong, UNSW, Newcastle, Melbourne, Flinders and Tasmanian medical schools, have led to assessment benchmarking activities and ongoing collaborative exchange for peer review and best practice.

Figure 5: Key findings from Community Research-initiated research on teaching research

What is the Community Research Program achieving?

Increased research engagement: Community Research has become a focal point on the path toward increasing research engagement for WSU students. This compulsory component is positioned alongside additional research (e.g. embedded Honours, an intercalated year-long Bachelor of Medical Research leading to MPhil and PhD) and thus careers as clinical academics and clinician researchers (see Figure 6).

Figure 6: Student Profile: Marra Aghajani, Year 4 MBBS

Expedited ethics review: Another achievement of wide impact has been the creation of an expedited research ethics review and approval process (with advice from Wollongong colleagues). This process has now been replicated for WSU General Practice research, Physiotherapy research, WSU and Charles Sturt University medical education research and evaluation, and in a unique partnership with the NSW Aboriginal Health and Medical Research Council (see Figure 7).

Each year approximately 20 CR project proposals are submitted to the WSU Human Research Ethics Committee (HREC) as sub-project amendments, under an overall approval for low and negligible risk medical student research, and approved within two to four weeks. As one of their supported learning-by-doing experiences, students complete ethics amendment applications using templates for project protocols, participant information sheets and consent forms. These are submitted to WSU HREC only after CR team review and students completing any necessary revisions. This pathway has saved students and supervisors much time and effort, reinforced learning about research ethics, prevented students from being discouraged about future research involvement (as reported by early cohorts who had to obtain full ethics approvals), and encouraged projects better suited to the community engagement aims of the CR program.

Figure 7: Promoting Aboriginal Health Research: partnering with the Aboriginal Health & Medical Research Council of NSW (AH&MRC) Human Research Ethics Committee (HREC)

Peer-reviewed publications: A 2017 audit revealed 44 students had published, 65 students had delivered conference presentations and 41 had manuscripts undergoing peer review. The very successful Northern Rivers (see Figure 2) Rural CR team, working with local clinicians, researchers and community partners, has alone produced 21 peer-reviewed research publications with CR students as authors, and the findings of these publications are being cited and influencing practice. Tracking research outcomes into the postgraduate years is not straightforward; similar to monitoring graduate practice locations, reporting these important outcomes calls for a unified and collaborative approach between medical schools.

Continuous improvement

Lessons from our decade of CR teaching experience, together with contemporary developments in medical education, continue to guide the program’s evolution as it is replaced by the MD Project. As a result, research skills teaching has now been re-sequenced and strengthened, and there is greater horizontal and vertical integration with Population Health, EBM, biomedical and clinical science disciplines.

MD Projects are completed by individuals rather than groups of students. While the work required of students has been moderated, CR experience shows that allocated time is crucial, so this has been increased. CR experience in recruiting supervisors and ensuring that projects are suitable for students with no research experience has led to a surplus of CR projects each year, but many more are required for the MD. The CR team – now in charge of designing and implementing MD Projects – strategically used opportunities provided by WSU partnerships with new academic health precincts in Western and South Western Sydney, the Central West and the Northern Rivers districts of NSW to increase the number and range of projects.

MD Projects now cover a comprehensive suite of student interests and professional capabilities in medicine, including biomedical, population health, medical education and rural research, Aboriginal Health and clinical quality improvement. Regardless of whether it is the clinician, patient or Aboriginal or rural community, all projects remain grounded by engagement with community and that community’s needs. For example, the WSU rural programs in Bathurst, Lismore and now Orange NSW (in partnership with Charles Sturt University) are designed to deliver comparable learning and assessment that is still relevant and contextualised to local communities. Importantly, these research programs build rural research capacity and support rural careers for future doctors.

Growth in research capacity and medical workforce are vital to maintaining the strength and continuity of the teaching team and for reciprocity when partnering with under-served communities, so that research becomes core business and is resilient in the face of COVID and other unanticipated challenges.

Ultimately, impact on graduate practice and life-long skills such as problem solving, teamwork and time management is paramount. Whether graduates are on clinical or clinical research career paths, they often report such outcomes, and that literature searching and appraisal needed to do research has helped them become more effective users of research for patient care (see Figure 8).

Since 2010, the CR program has purposively and pre-emptively adapted to shifting conditions but remained focused on teaching and producing rigorous, ethically approved research that is underpinned by the School’s social accountability mission to be relevant, embedded and of benefit to the communities that it serves.

Figure 8: Impact on graduate practice and different career paths: Mohammad Rehmanjan and Benji Pfister

APPENDIX

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

ANU Medical School’s Advanced Research Project addresses the need for greater research readiness by offering a research skills pipeline prior to commencement of PhD studies. 

Why was the program undertaken? 

The ANU MChD degree is a post-graduate medical program with a particular focus on research. All students complete an independent research project within their two pre-clinical years: the requirement is to submit a report in the form of a scientific manuscript by the end of Year 2, based on approximately 120 hours of research in a field of the student’s choice.

Starting from its establishment in 2004, the ANU Medical School offered its students the MBBS/PhD Conjoint Program. This was a unique opportunity for medical students interested in becoming clinician researchers to graduate from medical school with a PhD. Interested students applied concurrently for a school-funded PhD scholarship and medical school entry. If successful, the candidates commenced full-time research in Year 1, deferring their medical studies for two years. After two years, according to the plan, the students commenced full-time medical school, completing their higher degree part-time while studying medicine (Table 1, Original Model).

By 2015, it became clear that there were problems with this program. Students were unable to complete sufficient research in the first two years and required extensions, delaying the commencement of the MChD and extended scholarship support. More concerning was that students felt the promises to integrate the two aspects of the program and support them in gaining transferable research skills and clinical research experience were not being met.

To address these concerns, a different model was designed whereby students could commence their research in years 2 and 3 (Table 1, Revised Model). However, this model did not produce the desired outcomes either, with supervisor/student relationship issues and a continued lack of research readiness on the part of those entering the program.

Table 1. Organisation of Original Conjoint MChD/PhD model and Revised Advanced Research Project (ARP) model.

In 2017, the HDR team devised the Advanced Research Project (ARP) program to address the need for greater research readiness by offering a research skills pipeline prior to commencement of PhD studies. This program leverages the MChD research project by allowing students to use it as part of their PhD if they meet the prerequisites required to enter the program. These prerequisites include: having H1 honours or equivalent, a willing supervisor, achieving a higher-level pass on their research project, being awarded a PhD scholarship based on merit, and having approval from the director. In this way the ARP acts as a filter, optimising admission to the conjoint program by testing students’ ability and resolve prior to their commencing.

Although the ARP was primarily designed for prospective conjoint MChD/PhD students, all MChD students are eligible to enrol. All projects must relate to the practice of medicine, while prospective conjoint MChD/PhD candidates and their supervisors are advised that their projects should be able to be extended to a PhD program.

The objectives of the ARP are to:

• Provide students with research knowledge required for undertaking useful health and medical research
• Provide opportunities for developing and applying research knowledge and skills
• Support students to undertake excellent research during their research project course.
• Provide an instrument to accurately assess MChD student’s suitability for undertaking a conjoint MChD/PhD.

How was the program implemented?

The ARP is led by a team of active researchers, experienced in undergraduate and higher degree research supervision. The team is experienced in systematic review, and qualitative and quantitative methods to conduct social science, laboratory science and translational and clinical research, and the course leverages this combined knowledge and experience to deliver research-led education. This cross-disciplinary, mixed-methods team also serves to prepare students for the interdisciplinary nature of both medical practice and clinical research. In addition, the students themselves bring a rich array of experience; many have prior research experience including PhDs. Therefore, the peer to peer experience is crucial in promoting energy, enquiry and adaptation.

A critical element of the ARP is exposure to a broad range of approaches, not just the narrower range relevant to the student’s own project. Students are actively encouraged to experiment in their interpretation of the content and to discuss their research successes and dilemmas. In this way, a student completing, for example, a lab-based biomedical project, will gain understanding and insight into qualitative patient experience research from peers and through the taught content.

The specific course learning outcomes are to:

1. Identify research questions, and design and implement a research plan
2. Perform sophisticated, critical analysis of the literature
3. Analyse and summarise research data sets
4. Synthesise meaning from data and observations and present coherent arguments
5. Produce written research outputs (grant applications, reports, publications) to publication standards
6. Develop project management skills commensurate with the planning and undertaking of an extended research plan, including setting goals, meeting deadlines and communicating progress against agreed milestones
7. Develop persuasive written communication skills based on the judicious use of evidence to support a comprehensive research plan, as outlined in a grant proposal sufficient to cover the minimum requirements to successfully undertake the research
8. Develop capacity to provide constructive feedback through peer review of the work of others, and to respond to constructive feedback form peers, supervisor and research mentor.

The program is project-based and students complete the course in parallel with their core medical studies during the pre-clinical phase of the MChD. All students enrolled in the ANU MChD must complete a research project but the ARP differs in four ways:

• The scale of the project is larger. Typically, we expect about twice the time commitment of a regular Research Project.
• ARP students must complete a series of online lessons (KuraCloud, Lt Lifescience eLearning Platform, ADInstrument) and face-to-face tutorials (via Zoom during COVID), introducing them to key research concepts, skills and processes.
• A focus on peer review, peer mentoring and collaborative engagement with fellow students.
• It includes a critical mentorship model, wherein the students have access to advice, support and facilitation from established researchers in medical science, clinical science and social science.

The curriculum for the ARP is a live document which has evolved over several years in response to student needs, student feedback and our review of the final submissions. In 2021, the materials covered nine key areas in Year 1 and four areas in Year 2. These are summarized in the Appendix.

There are also two formative assessment items that students complete in the planning phases of their project: a critical presentation of three key papers from their literature review and how the review has informed their design; a draft introduction. These formative assessment items are useful, both in terms of the substantive task but also as vectors for peer review and collaboration. Each of these submissions receives feedback from both staff and students. Completion of these formative assessment tasks, as well as 80 percent attendance and completion of live and online lessons, is required to maintain enrolment. Students who do not meet this expectation for engagement are transferred to the regular research project stream, where they can continue the same project at a smaller scale.

What is the program achieving? 

Outcomes and Evaluation

Since its inception, two cohorts of students have completed the ARP. The outcomes have been surprising, with effects beyond the original purpose.

Enrolment: The course has been steadily gaining enrolments as it has settled into the course landscape. A quarter of the yearly cohort are now enrolled in the advanced stream.

Conference Presentations and publications: Currently, we don’t have reliable data for these outcomes but are developing strategies to capture this data more rigorously. We would normally have five or six students from the entire year applying for support to attend and present at conferences, but the disruption caused by the pandemic has prevented our cohorts from participating.

Conversion to MChD/PhD: The program has not yet converted a student to the conjoint program. However, perhaps counter-intuitively, we consider this a success. Part of the reason this program was instituted was to ensure that the students who enrolled were able to meet the expectations of the PhD program and produce high-quality research in a timely manner. Allowing the students to engage with publishable research at an earlier stage in their studies, in a lower-stakes environment, has facilitated reflection by the students on their capacity and time commitments, and shown them not to start something that they can’t finish. Having this research experience (and possible associated publication) has given many of our students the knowledge and confidence to know whether a higher degree is something they want to aspire to in the future, as well as insights into when might be appropriate for them.

Student evaluation: The most exciting outcome of this program has been the enthusiasm shown by emerging clinician researchers eager for the challenges of research and excited to be part of it (feedback from students sent without request is included in the Appendix). The following quote is a great accolade and strengthens our belief in the value of the ARP: “Inclusion in the MChD’s Advanced Research stream has been a highlight of my medical education so far.”

Reflections and goals for the future

There is no doubt that this program provides a rich, student-centred experience for medical students with aspirations to become clinician researchers. Increased cohort size has necessitated more peer-to-peer feedback, prompting more debates and discussions, which we regard as a very valuable development. We envisage future development will involve structuring the course to facilitate even more peer-to-peer engagement, development of our online resources based on student feedback, and mechanisms to ensure a higher percentage of publications per student in the program.

The cost of the program has been minimal. Members of the team which teaches into the course contribute approximately 30 hours each in face-to-face teaching time, facilitation, assessment/feedback and one-to-one interviews.

Adjusting to online teaching during the Covid19 pandemic has been a reality for all medical schools. In Canberra, we have enjoyed a hiatus where we have been face-to-face for a short period in 2021. It is clear from this experience that face-to-face is preferable because it facilitates easier communication, however, the online environment has had advantages, such as easier inclusion of students with childcare responsibilities and the opportunity to record sessions for review.

Summary

The ARP has fulfilled its role as a filtering program to ensure that only research-ready students enter the conjoint MChD/PhD stream. However, it has also filled an important gap in medical education for students who want to be active researchers in their medical career, regardless of whether they undertake the conjoint program.

APPENDIX

1. Taught Curriculum (2021)

2. Student Feedback

The feedback below was sent to us without request (unsolicited comments) It is arguably the most powerful evidence of the success of this initiative.

2019 – “Just wanted to send a belated message of appreciation for your work with the advanced research program and the mentorship you provided. Despite the challenges associated with research, I learnt an incredible amount over the past 18 months and couldn’t have done it without help.”

2020 – “The 2020 ARP students just wanted to send through a big thank you for all your hard work helping us in 2019 and 2020. It was a crazy year and we appreciate you still making the time for us. We all learnt a lot about our individual research topics and also learnt a lot about ourselves as researchers. We’ve put together a list of “what I learnt doing a research project” tips and tricks for future ARP students. The list is quite long – a testament to our revelations! I hope it’s helpful for future students, or even just helpful for you both to have a giggle!”

2021 – “The Advanced Research Project run by the ANU Medical School was an exciting and innovative program that allowed me to not only retain but continue developing myself as a young researcher. Through dedicated teaching staff, additional classes, extra support and a collaborative environment, we have all been supported to produce creative and high-quality research. It also fostered an environment where students, passionate about research, could come together to collaborate, share ideas and support each other through the trials and tribulations of biomedical research. It is exciting for me to look at my colleagues and wonder what wonderful contributions they will make to their chosen fields.

While uncertain about whether I wanted to pursue a pathway as a clinician scientist, I knew that I had a passion for research and after a successful honours project, I was dismayed to realise that medical school would see me lose many of the research skills I had worked hard to develop. However, the Advanced Research Program has given me the opportunity to form research networks, begin to publish my work and speak at conferences. More than this, it has equipped me with the confidence and enthusiasm to pursue a PhD. While challenging to fit in a busy medical curriculum, the program has cemented my intention to become a clinician scientist, with feet in both the clinical and research world. It compels young doctors to meet a high standard and has given us skills that will undoubtedly help with our clinical training. The program gives students the opportunity to uphold the highest traditions of scientific endeavour, of which medicine rest upon. It is also humbling and a privilege to be mentored by senior researchers that have distinguished themselves and generously share their insights with us.”

“Inclusion in the MChD’s Advanced Research stream has been a highlight of my medical education so far. It’s allowed me access to a small community of student researchers who have helped me navigate this element of the course, an opportunity that was especially welcome in 2020 during lockdown, when interaction amongst our cohort was minimal. It has also elevated the quality of my research, providing guidance in developing a project, connecting me with great supervisors and prompting me to submit work ahead of deadline.”

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

The compulsory, six-week, full-time research training program introduced by Monash Medical School in 2020 has been a great success with students, despite initial concerns about the school’s capacity to supervise more than 500 students per year doing short research projects. 

Why was the program undertaken? 

The Scholarly Intensive Placement was one of several changes introduced to the Monash medical degree in its transition from MBBS (Hons) to Masters Degree (Extended) BMedSc/MD. 

To provide context, the Monash medical degree is a large (more than 500 students/year level), geographically distributed degree operating across Monash Australia and Monash Malaysia campuses (more than 33 clinical locations in metropolitan and rural Victoria and Malaysia). Most students at Monash Australia and all students at Monash Malaysia commence directly from high school into a five-year degree (Years 1-5). Monash Australia also has a four-year graduate-entry degree (Years A-D). The final three years are clinical years and are identical for both cohorts. A full study load is 48 credit points per year. 

Three major changes were made to the clinical years during the transition to the MD: 

1. Introduction of a compulsory series of new, interactive online Research Methods in Medicine modules, which include a major data analysis assignment in Year 3/B. 
2. A doubling of the Patient Safety Module (from six to 12 credit points) in Year 5/D 
3. A compulsory new six-week, full-time 12-credit point unit called Applied Studies in Medical Research and Professional Practice in Year 5/D, replacing an elective rotation. This unit is colloquially known as the Scholarly Intensive Placement (SIP). 

Consistent with the Australian Quality Framework (AQF) definition of a Masters Degree (Extended), the overarching aim of the SIP is to develop “individuals who apply an advanced body of knowledge in a range of contexts for professional practice and as a pathway for further learning” [1]. The SIP was designed to enable final-year students to work full-time for six weeks on a scholarly activity to gain in-depth knowledge in an area of interest, relevant to medicine. The unit was strategically placed in the final year to enhance students’ research skills, particularly their ability to search and critique the literature, immediately before they commence their lifelong journey as evidence-based medical practitioners.  

We drew inspiration for the SIP program by reviewing published literature for similar research-intensive experiences for medical students at other universities (for example [2–5]) to identify key success criteria. The review indicated that having an organisational research culture and protected time within a well-structured and well-supported program, with quality supervision and a degree of student autonomy and project choice, would be critical to improve student research skills, attitudes and scholarly outputs [6]. We considered surveys of medical students about their research experiences and attitudes to research [7, 8] and sought input from Monash University student representatives. We also drew inspiration from a very popular Monash undergraduate unit for Bachelor of Science and Bachelor of Biomedical Science students, called Action in Research. 

We knew that the project types undertaken by the SIP students needed to be broad-based, given the large student numbers and geographic distribution of the Monash MD program. We also needed project options that utilised research skills but could be overseen by supervisors who might not be research-active themselves.  

We envisaged that projects would largely fall under one of three (not mutually exclusive) streams:  

1. A research stream, where students could contribute anywhere along the pipeline of a research project – a literature review, designing a project, developing research tools (e.g. survey), data collection, data analysis or project write-up. 
2. A professional practice stream, where students could contribute to a professional practice issue in a clinical setting (e.g. quality improvement audits, development of clinical guidelines, governance or policy documents, review of treatment and/or management options for a specific disease). 
3. An education stream, where students could develop or evaluate educational materials for patients, the general public, other students or health professionals. 

How was the SIP program implemented?  

The SIP is led by the Director of Medical Student Research and six dedicated SIP Coordinators, responsible for recruiting supervisors, approving topics, reviewing students’ preferences and supporting SIP students and supervisors at their school. The Director and SIP Coordinators meet monthly to ensure consistency across sites, resolve unforeseen issues and identify opportunities for improvement. 

No financial incentives are given to SIP supervisors but the faculty funded five 0.2 FTE SIP Coordinator roles, and administrative support is provided by current staff at each school. The cost of the program, therefore, is primarily academic salary support equating to less than $200,000 per year.  

A central SIP website has been developed to provide students and supervisors with an overview of the program. Each school also has its own SIP website to promote the range of projects available at that school. Students and supervisors receive a SIP guide, and a dedicated learning management system (Moodle site) contains the SIP guides, assessment instructions and additional support resources, and links to upload assessment items. At any one time, there are 80-90 students undertaking the SIP across six clinical Schools in Australia (15 sites) and Malaysia (three main sites). 

To minimise unexpected delays, SIP projects must either already have or not require ethical approval; alternatively, the development of an ethics application can form part of the SIP project itself.  

Learning Outcomes 

The learning outcomes for the SIP are: 

1. Utilise specialist knowledge and skills to justify the need for a research, teaching or professional practice issue to be investigated or evaluated. 
2. Devise and implement a plan for the placement and identify key outputs. 
3. Review, synthesise and critically appraise clinical and scientific literature in a specific area of medical science, education or professional practice. 
4. Practice and demonstrate an understanding of academic integrity, research integrity and ethical behaviour in the context of medical science and/or delivery of care. 
5. Collect and categorise information related to a key question relevant to the community and to medicine. 
6. Analyse and summarise information related to a key question relevant to the community and to medicine. 
7. Justify and reflect upon approaches to solve a complex problem relevant to their placement. 
8. Communicate critical concepts and findings to a professional audience in oral and written formats. 

Assessment 

The SIP assessment strategy consists of five assessment items (Items 2 and 3 are Hurdles):  

1. A series of online modules on Good Research Practice, Academic Integrity and Citing and Referencing, all assessed by a quiz 
2. A Student-Supervisor Learning Agreement to ensure the student understands the supervisor’s expectations, tasks to complete and what to include in the Scholarly Report 
3. A 4000-word Scholarly Report about their SIP project, including a 250-word executive summary (abstract) 
4. An oral presentation about their SIP project  
5. A reflection on their SIP experience. 

What is the program achieving?  

Based on formal and informal student and supervisor feedback, the SIP has been a resounding success, despite very significant impacts from COVID-19 in its first and second years of operation.  

Prior to starting the SIP in 2020, there were substantial concerns about the capacity to supervise more than 500 students per year doing short projects, but this proved to be an unfounded concern. In 2021, there have been about 230 separate supervisors, each supporting between one and six students for the year. Informal feedback from supervisors indicates that they have been very impressed with the dedication and quality of the work that the SIP students are producing. Evidence from students’ oral presentations, scholarly reports and student reflections also indicates that students are achieving the learning outcomes, learning a great deal about their topics, and reflecting on the impact of the SIP experience and how they will take their scholarly learnings forward into their clinical practice.  

However, the COVID-19 pandemic did have major impacts on the SIP program in both Victoria and Malaysia. In 2020, COVID began to impact clinical placements during the second rotation for the year with the strictest lockdown in Melbourne (Victoria) lasting for four months. In Malaysia, a Movement Control Order in 2020 caused all medical students to be removed from clinical placements for about five months. To keep students meaningfully occupied during this time, many SIPs were altered to run concurrently with the limited clinical placements that were available – over an extended period rather than six-weeks full-time. The students and supervisors coped remarkably well with the rapidly changing and evolving situation, but many projects did have to be altered at short notice so they could be completed remotely.  

The impact of COVID-19 on the SIP has continued to be very significant in Malaysia in 2021 but at Monash Australia, the program has reverted to six-weeks full-time for all final-year students, with relatively few projects impacted by Victorian/Melbourne lockdowns. 

A selection of SIP students are profiled in internal and external media articles to promote the program, the variety of projects available and the outcomes that can be achieved from the SIP: 

• Rethinking pandemic preparation and pivoting the Monash MD 
• Anaesthetics audit gives student experience in pain medicine 
• Medical teaching innovation yields results for infants at risk of cerebral palsy 
• Migraines causing pain for the economy 
• Medical student relay delivers a new Cochrane review 
• Student helps develop palliative care tools 

A manuscript describing the first-year evaluation of the SIP program and the impacts of COVID-19 on the program will be submitted for publication soon. It will be important to continue evaluating the SIP in future years when the impacts of COVID-19 are further reduced, however, feedback thus far indicates that the vast majority of students and supervisors have had positive and satisfying experiences and that the SIP is achieving its objectives to enhance students’ research skills, confidence to practice EBM and interest in undertaking research and other scholarly work. 

References: 

[1] Australian Qualifications Framework Council, Australian Qualifications Framework, 2nd Edition, 2013. p. 59. 

[2] Bierer, S.B. and H.C. Chen, How to measure success: the impact of scholarly concentrations on students-a literature review. Acad Med, 2010. 85(3): p. 438-52. 

[3] Chang, Y. and C.J. Ramnanan, A review of literature on medical students and scholarly research: experiences, attitudes, and outcomes. Acad Med, 2015. 90(8): p. 1162-73. 

[4] Havnaer, A.G., A.J. Chen, and P.B. Greenberg, Scholarly concentration programs and medical student research productivity: a systematic review. Perspect Med Educ, 2017. 6(4): p. 216-226. 

[5] Laskowitz, D.T., et al., Engaging students in dedicated research and scholarship during medical school: the long-term experiences at Duke and Stanford. Acad Med, 2010. 85(3): p. 419-28. 

[6] Cornett, M., et al., A realist review of scholarly experiences in medical education. Med Educ, 2021. 55(2): p. 159-166. 

[7] Eley, D.S., et al., What will it take? Pathways, time and funding: Australian medical students’ perspective on clinician-scientist training. BMC Med Educ, 2017. 17(1): p. 242. 

[8]  Muhandiramge, J., et al.,The experiences, attitudes and understanding of research amongst medical students at an Australian medical school.BMC Med Educ, 2021. 21(1): p. 267. 

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

In 2020, the UNSW medical school approved a proposal to leverage the most successful aspects of its research training program – determined by student and supervisor feedback – and to provide high-performing students with an additional qualification from the research year. 

Why was the project undertaken?

For more than 15 years, a research component known as the Independent Learning Project (ILP) has been an integral component within the UNSW Medicine program.

The ILP spans Year 4 of the six-year undergraduate program and was designed to be a supervised research project in any field relevant to medicine, ranging from laboratory benchwork to fieldwork in Aboriginal and Torres Strait Islander communities to clinical audit. The intention to develop students’ research and critical evaluation skills through the project was backed up with surveys of students and supervisors undertaken regularly, to improve the research year experience (Hunt et al; Uebel et al., 2021).

In 2020, a proposal to leverage the most successful aspects of the ILP (determined by student and supervisor feedback) and to provide high-performing students with an additional qualification from the research year was approved. The main aim of these changes was to enhance the educational opportunities for students in their research year, and tailor the program to their needs and interests with the introduction of a blended research/coursework paradigm.

How was the project implemented?

Due to the nature and extent of our research curriculum redesign, an extensive consultation process was undertaken, which included all heads of schools and institutes within the Faculty of Medicine & Health, all affiliated medical research institutes and the UNSW Medical Society (student-run body). Upon approval, a series of online webinar events was run for students, research supervisors and schools to facilitate implementation of the program.

Program level enhancements – giving students a choice to build their own research program

Following a change in eligibility criteria, an increased proportion of students can now undertake a BSc (Med) Honours program. Previously, only the top 30 students were invited into the program, based on their weighted average mark. We also changed the structure of the research year by reducing the research component (previously 100%) to enable integration of a compulsory course on value-based health care in clinical practice as well as advanced coursework (Honours only). This change has allowed us to offer specialised teaching, especially in emerging research fields, that complements the research experience. For example, a student undertaking an Honours research project in personality disorders can now select an advanced course in Mental Disorders, Personality Disorders and Crime offered by the school of Psychiatry; this would both add value to the research project and allow the student to study alongside people outside the medical program.

In 2021, over 80% of Year 4 medical students selected to undertake the BSc (Med) Honours program (all eligible students selected this option). For 2022, we have further refined the Honours program to give students the choice of a research-intensive or coursework-intensive experience. As a result, students can now select from one of the following streams:

1. ILP – 21 hours per week of research activities over a 30-week block. This is a less demanding program and students can complete their general education requirements alongside the research project.
2. BSc (Med) Honours – Research Intensive – 28 hours per week of research activities over a 34-week block, plus seven hours per week of advanced coursework. Students select one course from a list of 30+ that complements their research project. For example, statistical or qualitative methods, cancer pathology, health data science, molecular pharmacology, human genetics, health leadership, workforce management.
3. BSc (Med) Honours – Coursework Intensive – 14 hours per week of research activities over a 34-week block, plus 21-hours per week of advanced coursework related to a predetermined specialisation. For example, in 2022, students can undertake a BSc (Med) Honours in Clinical Artificial Intelligence (AI), which consists of four advanced courses in AI [1] and a research project that will complement the coursework. Students successfully completing this program will obtain a BSc (Med) Honours – Clinical AI (specialisation). Other coursework intensive streams are being developed for 2023.

Figure 1. A schematic representation of the 3 main options available to UNSW Year 4 medical students. In Year 3, students approach potential supervisors across UNSW and our affiliated medical research institutes to negotiate a research project in Year 4. During that process, they select the stream they would like to undertake based on their interests. Please note, entry requirements for Honours are based on a minimum WAM of 65 obtained from years 1-3.   

Coursework level changes – Research with Aboriginal and Torres Strait Islander peoples 

As part of our research education redesign agenda, Dr Brett Biles, Director of Indigenous Health Education at UNSW, developed a curriculum on researching with Aboriginal and Torres Strait Islander peoples that all medical students must engage with during their research year. This consists of a series of online teaching modules (Aboriginal and Torres Strait Islander history; Cultural competence in Aboriginal and Torres Strait Islander Health Care; Research with Aboriginal and Torres Strait Islander peoples) and the following workshops run across the Year 4 medicine program:  

I. Self-awareness, positionality and reflective health care  

II. Ethical frameworks and principles in Aboriginal and Torres Strait Islander research 

III. Collaboration in Aboriginal and Torres Strait Islander research.  

These fundamental changes were embedded in our research program in 2021, with the overall goal of teaching the next generation of clinical researchers the importance of researching with Aboriginal and Torres Strait Islander peoples in a culturally safe and respectful way. These online modules are currently assessed via a reflection activity in the Honours program, but in 2022 this assessment will be moved to our new compulsory course Value-Based Health Care in Clinical Practice. 

Coursework level changes – Using scientific methods to improve health care delivery 

In 2022, a new compulsory course titled Value-Based Health Care in Clinical Practice will be integrated into the Year 4 curriculum (ILP and BSc (Med) Honours). This course aims to extend the research experience gained during ILP or Honours and enable students to apply evidence to inform their decision making in clinical practice.   

Students will gain an understanding of the meaning of ‘value’ in healthcare, and how to apply research evidence to re-design models of care that improve efficiency and create value for patients. This course will equip students with the principles of quality improvement (e.g. plan-do-study-act, lean six sigma, quality management), outcomes measurement (e.g. patient-reported outcomes, health-related quality of life) and economic analysis (e.g. cost-effectiveness, opportunity costs) to lead service transformation and professional development in preparation for future medical practice.    

Applying improvement methodology and drawing on their research experience, students will submit a substantial project report focusing on value-based interventions to improve Indigenous health within acute care or community settings.   

In summary, the Year 4 Medicine program will enable students to develop and apply their research skills in the context of clinical practice, with a focus on Aboriginal and Torres Strait Islander health and wellbeing. Our approach of giving students with diverse research interests a variety of research options complimented by advanced coursework is intended to enable students to tailor their education in research to their needs and interests, and maximise the impact of the research year on their future career opportunities and contributions to research. 

What is the project achieving? 

The overall aim of our research teaching redesign project was to enable UNSW medical students to build a research program based on their interests and future goals. The program has now evolved to the point where students can select a research topic of interest (pre-clinical or clinical), the level of research undertaken (ILP, coursework or research intensive) and the courses they would like to study that can enhance their research experience. This has also allowed us greater flexibility to alter our research program by introducing new advanced coursework at any point, based on emerging fields of medical research. It also allows increased diversity of areas and topics for students to pursue. 

Benchmarking and Evaluation   

In 2019, a network of academic leads of MD research from Australian medical schools was initiated by Professor Wendy Hu (Western Sydney University), with the aim of exchanging and developing best practice in enhancing student research experience and program governance. As early participants, this facilitated our alignment of student learning outcomes, research and supervisor training, and assessment marking. The network continues to grow and provide benchmarking for our research teaching in medicine at a national level.        

Finally, a major assessment for both the ILP and Honours year is a final research report written in the form of a manuscript suitable for submission to a peer-reviewed journal. We are currently undertaking an audit to identify published outputs from Year 4 medicine student research projects, as well as a qualitative study exploring the experiences of students and supervisors of the Year 4 program. Preliminary data demonstrates that the proportion of students who published has increased from 28% in 2007 to 50% in 2015. 

References  

Uebel K; Iqbal MP; Carland J; Smith G; Islam MS; Shulruf B; Nathan S, 2021, ‘Factors Determining Medical Students’ Experience in an Independent Research Year During the Medical Program’, Medical Science Educator, http://dx.doi.org/10.1007/s40670-021-01340-9. 

Hunt JE, Scicluna H, McNeil HP. Development and evaluation of a mandatory research experience in a medical education program: the Independent Learning Project at UNSW. Medical Science Educator. 2011;21(1):78–85. 

[1] 1. Context of health data science 2. Computing for health 3. Machine learning 4. Clinical AI

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

The Research Program introduced for the Macquarie MD in 2018 ensures students focus on research that aligns with MQ Health’s strategic goal – to undertake research that improves the delivery of healthcare and the quality of patient and broader community lives.   

Why was the program undertaken?

The purpose of the Macquarie MD Research Program is to develop future medical doctors who understand the role and importance of research in guiding evidenced-based medicine (EBM) practice.

The Macquarie MD Research Program is built around the overarching Macquarie MD, building on the capacity for graduates to become scholars, research-informed practitioners and applied medical scientists. Students have the opportunity to undertake research projects that align with the broad spectrum of research strengths within MQ Health [1] and the Australian Institute of Health Innovation (AIHI), both of which promote MQ Health’s strategic goal – to undertake research that improves the delivery of healthcare and the quality of patient and broader community lives.

The stimulating research environment offered to students enrolled in the MD ensures that they will develop research skills, plan and implement a research project, and communicate their research findings and recommendations for healthcare and/or future research.

How was the project implemented?

Research knowledge and skill development is embedded throughout the Macquarie MD, culminating with the completion and presentation of a substantial research project. The program organises research training into Stage 1 (Years 1 and 2 of the course) and the completion and presentation of a research project over 18 months in Stage 2 (Years 3 and 4).

The core curriculum includes research methods, ethical considerations in research, statistics and safety. The research projects offered to students are diverse as they may come from the University Clinical Partners, any department within the Faculty of Medicine, Health and Human Sciences, MQ University Hospital and AIHI. The projects focus on making a scholarly contribution to learning health systems and may include projects related to: health systems development and delivery; infrastructure and resource use in healthcare; patient safety and quality; patient and clinician experience of service delivery; patient and professional reported determinants of health and wellbeing; medical education.

Macquarie MD research processes and principles include:

• Developing a group-based research project where students work together, with each student also required to answer a related but different research question and submit individual work for assessment.
• Identifying suitable research projects six to 12 months before the projects commence.
• Allowing students to preference their research project.
• Placing responsibility for ethics approval on supervisors to ensure it is appropriate and obtained in a timely manner.
• Training staff and students on Microsoft teams, which is the primary communication channel and protected storage site for data and documents related to the research projects. For each project, the relevant students and supervisors will form a team, and access to the team will be restricted to appropriate personnel so that data retention and ethical requirements are met.
• Having academic leads for the research project units across the student cohort.
• Showcasing the research in a final symposium in which students present work to a wide audience of peers, staff, clinical partners and external groups.

MD students chose their research topic from a list of projects submitted by interested supervisors. Supervisors nominate the number of students required to complete the project and work with teams of two to four students. The supervisory teams are comprised of both academics from AIHI and Clinicians from MQ Health, to further encourage and foster interdisciplinary relationships.

With guidance from their supervisors, the students devise their own research question on the chosen topic. Over the course of 18 months, the students further explore and develop their own research project by conducting reviews, data audits and/or extensive literature searches. Ten assignments are goal-posted along the pathway of research development and marked by supervisors and moderated by the Unit Convenors, culminating in a final manuscript (to the level of a British Medical Journal (BMJ) Open paper) and a ten-minute oral presentation across the Faculty of Health and Human Sciences, Doctor of Medicine & Doctor of Physiotherapy.

How the students are introduced to the range of research designs

At the end of Year 2, students are introduced to research methodology, alongside patient safety and quality work. Students have a core research curriculum, over a five-week block, to give them a foundation for their research tasks. The subsequent three research units build on their application in each topic area of choice.  Due to the variety of topics, students explore different research methodologies applicable to their individual tasks then work with their supervisory teams, presenting and interpreting work as qualitative and quantitative data.

Number of academic staff and students involved

Approximately 60 students participate in the program per annual intake. The academic staff are interdisciplinary, from across the Macquarie University campus. The average number of supervisory staff required is around 60 staff per cohort, however the actual supervisory staff numbers are fluid as they depend on several factors (exact number of students, and how many students each supervisor takes for each project).  Along with core supervisory staff there are other departments across the University which are also invested in the MD Research Program:

• Advisory Group and Executive Committee, comprising members across diverse integrated areas from within Macquarie University and MQ Health.
• Ethics / Library / Statisticians / Learning and Development Team.

To avoid delays and falling short of student research commitments, ethics needs to be obtained by the supervisors before the projects are selected. Studies ideally avoid live data capture and, where possible, focus on clinical settings, audits, clinical reviews for patient safety and quality improvement.

Learning outcomes: The research units have been designed around a capability framework: four graduate capabilities, each with two capability aspects (see Figure 1).

Figure 1. Macquarie MD Graduate capabilities and aspect

Research-specific learning outcomes, learning activities and assessments are designed to develop and align with the capabilities.

Assessment

Coarse grading is used throughout the Macquarie MD for all assessment tasks. A variety of assessment tasks are used for the MD research program: oral, written and logbook reflections. The final oral presentation is marked by internal and external examiners.

Most tasks will assess two or more Capability Aspects (see Figure 1. above), with a focus and Generic Capability Aspects. Students will receive a coarse grade and feedback for the Capability Aspects assessed in that particular assessment task. The coarse grades used in the Macquarie MD are outlined in Figure 2, below.

Figure 2. Macquarie MD Coarse Grading framework

The Macquarie MD also uses Entrustable Professional Activities (EPAs),  see Appendix.

What is the Program achieving?

Student evaluation: Each cohort of students evaluate the program via a university central survey.

Reflections on how program has evolved so far: Every indication to date has been that the MD Research program has met and exceeded all expectations. All the assessments within the MD Research Program have been reworked in alignment with feedback from supervisors. The AMC favourably reviewed our program in 2020.

Our first cohort of MD students, who commenced in 2018, completed the 18-month MD Research Program by presenting the results of their research at the Doctor of Medicine & Doctor of Physiotherapy Research Symposium on 25 June 2021. This half-day event saw 98 students from both courses present their research project in front of their peers and a panel of internal and external examiners from other universities and Macquarie. Due to COVID-19, this event was moved from face-to-face to Zoom, which proved a successful and dynamic virtual platform. The external supervisors were very forthright in praising the level of scholarly presentation and professionalism of the students.

Goals for future: We would like to be in a position of developing students’ capability to select their own research project by selecting a research team/professor they would like to work with.

Impact of Covid-19

• A major consequence of Covid has been that the students are unable to go to India, which has curtailed some of our planned research partnerships but overall has not affected delivery.
• Some projects that rely on clinical data capture have had to reshape their research questions.
• Planned live delivery of course work and the final research symposium was moved to an online platform.
• The final year group presentations at the research symposium 2021 was the virtual space, adapted for COVID.

APPENDIX

Figure 3. The Macquarie MD Entrustable Professional Activities list

Entrustable Professional Activities

The Macquarie MD also uses Entrustable Professional Activities (EPAs) to assess students. Each EPA is a fundamental clinical task that a student could be entrusted to perform by a clinical /research supervisor. EPAs are assessed by seeking an experienced assessor’s recommendation for the level of supervision the student would require when performing the EPA with real healthcare/research teams in the future using the following coarse scale:

There are 5 Stage 1 EPA and 9 Graduate EPAs in the Macquarie MD as illustrated in Figure 3 with G EPA 3 assessed in the Research Component and an R Level expected.

References

[1] MQ Health is Australia’s first university-owned teaching hospital.

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