120 articles met the inclusion criteria and were selected for inclusion in this scoping review. 94 related to non-intercalated degree options and 26 related to intercalated degree options. Results are listed for both the non-intercalated and the intercalated degree options below.
Non-Intercalated Degree Options (N=94)
The identified studies were published from 1976-2018. There was a wide geographical distribution of non-intercalated active research options. The majority were in the USA (40/94, 43%) and the UK (7/94, 7%). Several of the identified studies were from South America, the Middle East and Africa (see Table 3). In this table, we also included the World Bank definition of countries’ incomes as a proxy of medical school resources:
For the 2020 fiscal year, low-income economies are defined as those with a GNI per capita, calculated using the World Bank Atlas method, of $1,025 or less in 2018; lower middle-income economies are those with a GNI per capita between $1,026 and $3,995; upper middle-income economies are those with a GNI per capita between $3,996 and $12,375; high-income economies are those with a GNI per capita of $12,376 or more (22)
Table 3. Geographical distribution of non-intercalated studies / authors and World Bank definition of countries’ incomes as a proxy of medical school resources
Country
|
Frequency N=94
n (%)
|
World Bank Income Economy Classification
|
United States
|
40 (43%)
|
High Income
|
UK
|
7 (7%)
|
High Income
|
Australia
|
5 (5%)
|
High Income
|
The Netherlands / USA
|
3 (3%)
|
High Income
|
Sweden
|
3 (3%)
|
High Income
|
Canada
|
3 (3%)
|
High Income
|
India
|
3 (3%)
|
Lower Middle
|
Germany
|
3 (3%)
|
High Income
|
Malaysia
|
3 (3%)
|
Upper Middle
|
Turkey
|
2 (2%)
|
Upper Middle
|
Norway
|
2 (2%)
|
High Income
|
Any other country: Argentina, Australia / USA, Chile, Croatia, Germany / Croatia, Greece / UK, India / Malaysia, International, Ireland , Ireland / Malaysia, Japan, New Zealand, Pakistan, Portugal, Russia, Saudi Arabia, South Africa, Spain, UAE, West Indies
|
1 (1%)
|
Varies
|
Types of studies
Most of the included studies were original research articles describing the active research option or the outcome of the active research option. This scoping review identified one randomised control trial in which some students undertook active research in pharmacology and compared various outcomes in this cohort to the other cohort who undertook the traditional pharmacology curriculum (23)
Aims of selected papers
There was heterogeneity in the aims of the selected studies. The top three aims were: to describe the programme experience (36/94; 38%), to assess the impact of the research initiative on students (20/94; 21%), and to describe the research output of the initiative (17/94; 18%) (see Table 4).
Table 4. Study aims for non-intercalated papers
Aims
|
Frequency (Total=94)
n (%)
|
To describe program experience
|
36 (38%)
|
To assess impact of research initiative on students
|
20 (21%)
|
To describe research output
|
17 (18%)
|
To evaluate student attitudes to research
|
4 (4%)
|
To examine the effect of undergraduate research on career
|
3 (3%)
|
To stimulate student interest in research
|
2 (2%)
|
To try and increase trainees in a specialty by exposing them to research
|
2 (2%)
|
To try and synthesise published studies on medical student research
|
1 (1%)
|
To look at student motivation for research
|
1 (1%)
|
To investigate research opportunities for undergraduate medical students
|
1 (1%)
|
To describe research options available
|
1 (1%)
|
To see if the initiative increased recruitment to medical research
|
1 (1%)
|
To discuss reasons for failure of research theses
|
1 (1%)
|
To develop research capacity for all students
|
1 (1%)
|
To describe curricular content of research program
|
1 (1%)
|
To guide curriculum designers
|
1 (1%)
|
To evaluate student satisfaction with a research program
|
1 (1%)
|
Main active research option described
The most described research option was elective research projects (a mixture of elective summer research projects and elective projects at other times of the year) followed by mandatory research projects at various stages of the medical curriculum. Other options included clinical audits incorporating research skills (see Table 5).
Table 5. Non-intercalated Active Research Options Frequency (94)
Research Option
|
Frequency (Total=94)
n (%)
|
Mandatory Research Project(s)
|
40 (43%)
|
Mandatory research project (Longitudinal)
|
9 (10%)
|
Mandatory research project (Various points in curriculum)
|
11 (12%)
|
Mandatory research project (Final year)
|
5 (6%)
|
Mandatory research project (Year 5)
|
1 (2%)
|
Mandatory research project (Year 4)
|
3 (4%)
|
Mandatory research project (Year 3)
|
4 (5%)
|
Mandatory research project (Year 2)
|
3 (4%)
|
Mandatory research project (Year 1)
|
3 (4%)
|
Mandatory research project (Four weeks, not stated when in curriculum)
|
1 (2%)
|
Elective Research Project(s)
|
42 (45%)
|
Elective research project (Summer)
|
19 (21%)
|
Elective research projects (Timing unspecified / varies)
|
18 (20%)
|
Elective research project (Longitudinal)
|
3 (4%)
|
Elective research project (One year)
|
2 (3%)
|
Mandatory and elective project(s)
|
7 (8%)
|
Mandatory and elective project(s)
|
7 (8%)
|
Unclear if mandatory or elective research project
|
1 (2%)
|
Unclear if mandatory or elective
|
1 (2%)
|
Audit project
|
3 (4%)
|
Mandatory audit project
|
1 (2%)
|
Elective audit project
|
2 (3%)
|
List of options available in the 'research projects section'
|
1 (2%)
|
Various options
|
1 (2%)
|
Main outcome measure / findings recorded
The most common outcome measure recorded was output of active research (publication rates, conference presentations) (36/94, 38%).
The second area that featured the most was a quality measure of the description of the primary studies which has been labelled as ‘sufficient description of the active research method’ (26/94, 28%). We defined this as the ability of another medical school to reproduce the research initiative from the description given by the authors. (see Figure 2).
Intercalated Degree Options (N=26)
The selected studies were published from 1985-2018. There was less geographical variation in the location of the intercalated degrees studies / authors with most being in the UK followed by the USA. As US medical programs are graduate entry (‘MD’), the included studies from the USA described intercalated masters (two) and PhDs (four). (see Table 6).
Table 6. Geographical distribution of intercalated studies / authors* and World Bank definition of countries’ incomes as a proxy of medical school resources
Country
|
Frequency (Total=26)
|
World Bank Income Economy Classification
|
UK
|
13 (50%)
|
High Income
|
USA
|
6 (23%)
|
High Income
|
New Zealand
|
3 (12%)
|
High Income
|
Australia
|
2 (7%)
|
High Income
|
Chile * author
|
1 (4%)
|
High Income
|
Germany
|
1 (4%)
|
High Income
|
For the 2020 fiscal year, low-income economies are defined as those with a GNI per capita, calculated using the World Bank Atlas method, of $1,025 or less in 2018; lower middle-income economies are those with a GNI per capita between $1,026 and $3,995; upper middle-income economies are those with a GNI per capita between $3,996 and $12,375; high-income economies are those with a GNI per capita of $12,376 or more (22)
Main intercalated degree described
The most common intercalated degree described in the studies was an intercalated bachelor’s degree (14 papers), with intercalated BSc being most frequently described, followed by an intercalated PhD (six papers) (see Table 7).
Table 7. Intercalated Degree Frequency
Intercalated Degree Type
|
Frequency (Total=26)
|
Intercalated Bachelor’s degree
|
14 (54%)
|
Intercalated PhD
|
6 (23%)
|
Intercalated Masters
|
4 (15%)
|
Intercalated degrees various
|
2 (7%)
|
Main outcome measure / findings recorded
Discussions on feasibility and output of the intercalated degrees (publication rates / conference presentations) were reported most (5/26, 19% each) (see Table 8).
Table 8. Main Outcome measure / findings of intercalated degree options
Outcome Measure / Findings
|
Frequency (Total=26)
|
Feasibility issue discussion
|
5 (19%)
|
Output of active research
|
5 (19%)
|
Sufficient description of the active research initiatives
|
4 (15%)
|
Self-reported active research skills acquisition by the medical students
|
4 (15%)
|
Academic Performance
|
4 (15%)
|
Inspired students to do further research
|
3 (12%)
|
Report student motivations for doing research
|
1 (4%)
|
Analysis of key results of non-intercalated degree options – outcomes, quality measure and themes. Outcomes have been classified using the Kirkpatrick criteria (24)
Outcome 1: Output of Active Research Options (Kirkpatrick Results Criteria)
36 papers reported output of active research options. 17 (47%) of these articles discussed both student publications and student presentations at conferences. 16 (45%) of these articles discussed student publications. Three (8%) of these articles discussed student presentations at conferences. The details of the publications described ranged from ‘X articles were published’ to ‘X abstracts were submitted for publication’ to ‘X articles were published in an international journal’ to ‘X articles were published in peer reviewed journals’. Again, the details of conference presentations ranged from ‘ X were presented’ to ‘X were presented at local meetings’ to ‘X were presented at national conferences’ with a smaller number discussing ‘X were presented at international conferences.’
Outcome 2: Self-reported research skills acquisition by the medical students (Kirkpatrick Reaction Criteria)
17 papers described medical students’ self-reported skills acquisition. In nine (53%) of these papers, the students reported an increase in their research skills or knowledge. In two (12%) of these papers, the students reported an increased awareness of their research identity / thinking as a scientist (25, 26).
Outcome 3: Objective improvement on objective tests of research skills (Kirkpatrick Learning Criteria)
Three studies carried out pre and post tests on the students’ research knowledge. There was an objective improvement in students’ research skills in all three studies. A different instrument was described in each of the three studies. (27-29)
Quality measure of primary studies: Sufficient description of active research option
26 papers were rated to have had a sufficient description of the active research option. We defined this as the ability of another medical school to reproduce the research initiative from the description given by the authors. For this group of papers, student-rated positive satisfaction with the research option was the predominant measure (12/25, 48%). One study reported that students rated the experience lower than the teaching physicians involved (30).
Theme 1: Feasibility discussion - barriers to students doing research
Eight papers discussed feasibility issues or barriers to students doing research. A cross sectional study in 2016 looked at identifying underlying causes for failure of medical thesis projects and the constantly high drop-out rate in Germany from the supervisors’ perspective ( response rate to the study was 29%). The authors found that both thesis supervisors and medical students felt ill prepared for their roles in the process of a medical dissertation.(31). Murdoch-Eaton et al’s
2015 mixed-method study across five medical schools found that students identified practical difficulties in preparation before the project commenced, including time commitment and applying for ethical committee approval, as potential impediments to choosing a project that might provide research (32).
Theme 2: Mandatory versus elective research
There was an even mix between mandatory and elective research projects in the 94 non intercalated studies, and no study found one to be preferable to the other. In a 2017 qualitative study entitled ‘Impact of elective versus required medical school research experiences on career outcomes.’, the researchers found that although completion of research at medical school correlated positively with current research involvement, a pre-existing passion for research was the greatest predictor for a career as a physician scientist (p=0.008). Their study found that students who were primarily motivated by curricular requirement were less likely to pursue additional research opportunities. They reported that students who recalled positive medical school research experiences were more likely to pursue postgraduate research. The response rate to this study was low at 11.5%. (33)
There was also a discussion about the issues in relation to mandatory theses in Germany (31, 34). In the Diez paper, issues discussed by the authors included their thoughts on time pressures during medical school, how the dissertation was felt to be irrelevant to clinical practice and their perception that many projects were poorly designed. They discussed evidence from Germany that conducting research can delay graduation and may affect clinical skills because students working on projects attend fewer clinical teaching sessions and may not spend sufficient time preparing for examinations.
Theme 3: Amount of time taken to do research
Dyrbye and colleagues found that prolonging the break from medical studies to do an intercalated degree / research for more than a year can have detrimental effects on student performances in clinical exams (35) and in a second paper found that shorter experience seemed to yield outcomes similar to longer experiences (36).
Theme 4: Student Research Offices / Research Clubs
Several medical schools have developed ‘Student research offices’ in order to facilitate participation in extracurricular research (37, 38). Tuncel et al discussed ‘Student research clubs’ in a Turkish Medical School (39).
Analysis of key results of intercalated degree options – outcomes and ‘novel’ intercalated degree theme
As previously discussed by Jones and Amgad in their systematic reviews (5, 11), the effect of doing an intercalated degree on medical student performance and careers was the most featured outcome measure.
Outcomes 1: Performance and careers (Kirkpatrick Results Criteria)
Eight of the included 26 papers had publication rates, academic performance or careers in academic/research posts as a proxy measurement of the success of their respective intercalated degree programmes.
Outcome 2: Student perspective on doing intercalated degrees ((Kirkpatrick Reaction Criteria)
Five of the included 26 papers discussed the student perspective on doing intercalated degrees. The top two motivations for planning to doing intercalated degrees in Agha et al’s study of 358 second year medical students in London were career prospects and ‘a chance to gain publication’(40). Park et al found in their study in New Zealand of graduates who had completed an intercalated BSc from 1972-2005, that an interest in a career in research and academic medicine was the most commonly cited reason for undertaking an intercalated degree (41). Stubbs et al in their two centre cross sectional study in Bristol and Sheffield Medical Schools found that the participating students clearly valued the intercalated degrees and felt they gained a substantial advantage over their peers as well as skills helpful for their future careers (42).
Negative student perspectives on intercalated degrees included Agha et al’s findings that those who didn’t opt to intercalate cited financial (72%) and time costs (44%) and lack of interest in doing research (48%) as the main reasons given (40). Nicholson et al reported in their study in Aberdeen that the most common reason students opted not to intercalate was because they did not want to have another year of study (69.6%) or incur more debt (51.9%)(43).
80% of respondents in the Park et al New Zealand study encountered some problems during the intercalated year, with the most common reported being loss of contact with friends in the medical course (41). There was a small number involved in this study (30 / 50 responded)
Theme: More ‘novel’ intercalated degrees than traditional intercalated BSc
An intercalated BSc (44, 45) and Masters (46) in primary care were discussed. Jones et al felt that intercalated degrees could be aimed at a broader group of students than those wanting teaching hospital consultant posts or laboratory based science careers. Elwood et al discussed the community health option of a mandatory BSc in Nottingham as an alternative to the more traditional BSc (47). Muir et al described a medical education intercalated BMSc in Dundee in which students enhanced their learning through collaboration and opportunities gaining a better appreciation of the roles and responsibilities of staff roles and academic clinicians (48). Pearson et al described an intercalated BSc which involved students doing field research in foreign, lower income countries (49). Stellman et al discussed a one-year Masters of Public Health that students took between their third and fourth years in New York (50). Menger et al discussed an intercalated MB / PhD programme in Germany in which students perform a PhD thesis on a surgery-related research topic in their 6th year as a culmination of a research program from the third year (51). The aim of this programme is to increase the number of surgeon scientists.