Building a teaching-research nexus in a research ...

2015, 37: 174–180

Building a teaching-research nexus in a research intensive university: Rejuvenating the recruitment and training of the clinician scientist DIANN S. ELEY1 & DAVID WILKINSON2 1

The University of Queensland, Australia, 2Macquarie University, Australia

Med Teach Downloaded from informahealthcare.com by University of Queensland on 02/05/15 For personal use only.

Abstract Background: The continuing decline in clinician scientists is a global concern. This paper reports on a two-fold rationale to address this decline by increasing the number of students on a formal pathway to an academic research career, and building a ‘teaching-research nexus’ using the research intensive environment at our University. Methods: The University of Queensland has implemented a research intensive program, the Clinician Scientist Track (CST), for a select cohort of students to pursue a part time research Masters degree alongside their full time medical degree. To this end, the support of clinical academics and the research community was vital to achieve a ‘teaching-research-clinical nexus’ – most appropriate for nurturing future Clinician Scientists. Results: In three years, the CST has 42 enrolled research Masters’ students with the majority (90%) upgrading to a PhD. Research represents 33 different areas and over 25 research groups/centres across this University and internationally. Conclusions: Other research intensive institutions may similarly build their ‘teaching-research nexus’ by purposeful engagement between their medical school and research community. The CST offers a feasible opportunity for outstanding students to build their own ‘field of dreams’ through an early start to their research career while achieving a common goal of rejuvenating the ethos of the clinician scientist.

Introduction

Practice points

The call to nurture future generations of clinician scientists is clear and resonates across the globe. The majority of medical schools offer some combination of an MD–PhD degree program to exceptional students who undertake a long and arduous journey to fill a unique niche uniting basic science with medical practice. This is driven by the growth of translational research, defined as translating laboratory discoveries into clinical treatments, requiring scientists who are fluent in both basic and clinical science – clinician scientists (Lemoine 2008; Roberts et al. 2012). Integrating research and clinical training dates back to the late 1800s. Arguably The Johns Hopkins University School of Medicine provided an early model for medical education in the United States (USA). Figure 1 provides a timeline of the progression of the physician scientist within the American and European context (Hunskaar et al. 2009; Cox et al. 2012; Roberts et al. 2012; NIH NIGMS 2013). The history of these early programs indicate that a research higher degree instils an appreciation for research, imparts research rigour and inspires analytic and creative thought that motivates students to pursue careers in academic medicine (Laskowitz et al. 2010). Over the past decade, there have been increasing accounts in the literature about the decline in clinician scientists with multiple

Outstanding students can successfully undertake a concurrent MBBS-Masters that is mutually beneficial to students and the research community. Clear communication with research supervisors is critical to ensure a thorough understanding of the CST. Research projects should be flexible and provide scope to be broadened to a PhD. Identify researchers who are successful with supervising MBBS-Masters students because they are your ‘champions’ to help sustain the program.

factors responsible. Downward trends in the USA began during the 1980s and 1990s (Ley & Rosenberg 2005; Roberts et al. 2012). Ley and Rosenberg (2005) noted an upturn in MD–PhDs in 2002 possibly coincident with the NIH loan repayment programs which suggested that financial support is important to maintaining any sustained resurgence of interest in MD–PhD pathway. In the UK, a decline in numbers was evident in 2001 with similar financial barriers cited including better career reward structures (Bell 2003; Stewart 2012; Tooke & Wass 2013).

Correspondence: Associate Professor Diann Eley, School of Medicine, The University of Queensland, 288 Herston Road, Brisbane, Queensland 4006, Australia. Tel: +61 7 3346 5103; E-mail: [email protected]

174

ISSN 0142-159X print/ISSN 1466-187X online/15/020174–7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.947937


Rejuvenating the clinician scientist

Figure 1.

Timeline of the progression of the physician scientist within the American and European context.

Evaluation of MD–PhD programs have shown that students often do not have a clear idea of the career balance they want between research and clinical work but the majority tend to focus on patient activity and disease as their primary research focus. This raises questions as to whether these programs are focussing adequately on producing enough students who will be devoted to fundamental research (Ahn et al. 2007; Whitcomb 2007). Nevertheless, a recent study showed that a large proportion of internal medicine physicians trained through research pathways remained research active 10 years later (Lipner et al. 2012), and similar positive trends were shown in a study of MD–PhD alumni in 24 programs over 40 years (Brass et al. 2010).

What students’ want The majority of students entering medical school have little research experience but often indicate an interest during their medical degree. The main driver of this interest is to improve their CV with research experience and publications to give themselves a competitive advantage in early career choices such as resident matching and gaining a preferred residency training place (Reinders et al. 2005; Nicholson et al. 2010; Murdoch-Eaton et al. 2010; Siemens et al. 2010; Griffin & Hindocha 2011; Nikkar-Esfahani et al. 2012; Yap 2012). The main obstacles to medical students undertaking research are time, financial burden, lack of encouragement, and interested supervision (Nicholson et al. 2010; Murdoch-Eaton et al. 2010; Siemens et al. 2010; Nikkar-Esfahani et al. 2012). Students who undertake a research degree in medical school are a ‘unique breed’ (Yap 2012). Andriole et al. (2008) described over 88,000

USA MD–PhD students from 2000 to 2006 finding them to be less demographically diverse and mostly male, with career plans involving research.

The Australian context Most Australian medical schools administer a four-year Bachelor of Medicine Bachelor of Surgery (MBBS) degree with a mixture of graduate and undergraduate (school leaver) entry. A few schools have recently moved to the four-year MD and this trend is likely to continue. Although not as prominent as the MD–PhD programs in the USA and Europe, most Australian medical schools offer a similar option of an MBBS–PhD almost exclusively as an intercalated format, i.e., students interrupt their medical studies for a period of time to intercalate full time research. For example, the University of Melbourne have run a mandatory intercalated year as part of their medical program that allows students to graduate with an additional undergraduate degree (Bachelor of Medical Science) that can be research focussed (Collins et al. 2010).

Methods The University of Queensland (UQ) is a research intensive institution and its School of Medicine (UQSOM) is the largest in Australia. For 13 years, it has offered two intercalated research higher degrees (RHD); a Masters and a PhD both of which are exclusively research with no required coursework. The intercalated Masters requires a one year and the PhD a two year intermission between MBBS years 2 and 3 devoted solely to research. Students typically begin their RHD during their

175


D. S. Eley & D. Wilkinson

foundation years 1–2, intercalate their research year(s), and return to the clinical years 3–4 while completing the RHD on a part time basis. The intercalated PhD has maintained a low uptake with 10 MBBS–PhDs completed since 2004. These degrees are generally undertaken by students who already have substantial research backgrounds and are clearly focussed on a research oriented medical career. However, the intercalated Masters has never been popular. Even though it may be upgraded, or lead directly to a PhD students’ are reluctant to delay their medical training for a Masters degree. Between 2000 and 2011, there have been only two MBBS-Masters awarded. In 2010, the UQSOM considered the decline in RHDs in the MBBS. It was clear that the traditional RHD options for medical students were not enough to establish sufficient research output from the MBBS program. In response, the UQSOM developed a concurrent degree program to facilitate an early

start to a research career for very high achieving students. The Clinician Scientist Track (CST) allows a select cohort of students, with the ability and interest, to pursue a part time research higher degree – a research Masters – ‘concurrently’ with their full time medical degree – a Concurrent MBBSMasters. This model is uncommon in Australia. Our two-fold rationale: (1) addressed the decline in RHDs in the MBBS and (2) by combining an undergraduate medical degree with a postgraduate research higher degree, enhanced the notion of a ‘teaching-research nexus’ through development of relationships and collaborations between UQ’s rich research environment and its teaching and learning agenda. Ethical approval was granted through UQ’s Human Behavioural Ethics Committee. The strategy was two-fold: (1) make the Masters a more attractive option, thus increasing the uptake and (2) provide a program that encourages Masters students to progress to a

Table 1. Key features within each level of establishing the concurrent MBBS-Masters program which combines undergraduate and postgraduate degrees.

At the university/faculty approval level Proposals and subsequent approvals were obtained at the Faculty, Graduate School, and university levels. Necessary university policies and procedures were negotiated, documented and publicized on the university website. * Seeking advice from the academic head or dean of faculty in the first instance is invaluable to provide guidance through the university systems and steps to gain for approval of a new program. At the school development and administration level An MBBS research coordinator was appointed to develop and maintain the program and is responsible for: * providing one-on-one recruitment and counseling to each individual student to help ensure that only students who are academically, qualified and fully aware of the program requirements and committed to achieving success are approved to apply, * creating a dedicated website as a ‘one stop’ shop containing all information, and links to relevant sites plus a separate webpage with a regularly updated list of potential projects, supervisors and contacts suitable for student research, * publicizing the program through regular school wide information sessions for students and staff, * providing regular research ‘Expos’ open to all University schools, research centres and institutes interested in attracting medical students to research in their area, * facilitating ethical advice, review and approval, * facilitating statistical assistance when required, * working closely with the university graduate school regarding eligibility, enrolments and student progression through the Masters degree, * gaining support from the medical student society and collaborating with them on research related activities which both support and endorse the Clinician Scientist Track, * monitoring each student individually to ensure they maintain a satisfactory GPA in the MBBS and that acceptable progress through the Masters is maintained, * providing support and pastoral care to students and troubleshoot any arising problems between students and supervisors. At

the student level, students: Are responsible for understanding all the requirements and eligibility criteria for enrolling in a Masters degree. Must seek permission from the School and the MBBS Research Coordinator to apply to enroll in the Masters degree. Must fulfill all the normal eligibility requirements dictated by the Graduate School to enroll in and progress through the Masters degree. Are responsible for finding a suitable research project and supervisor for their Masters degree. The MBBS Research Coordinator will assist in this process to ensure the project is practical to undertake concurrently with the full time medical degree. Must begin with and maintain a minimum GPA in the MBBS degree throughout the concurrent MBBS-Masters degree. Understand that they are undertaking two separate degrees; the undergraduate MBBS (full time) and a postgraduate research degree (part time). Understand that they must fulfill the Graduate School’s required postgraduate ‘Milestones’ which is a three stage process that ensures students progress through their RHD with appropriate feedback and guidance throughout. For part time Masters’ candidates each milestone is scheduled at approximately 10 month intervals making it feasible for students to complete in three years. At the university research community level: Maintain a high level of awareness of the CST among the wider university research community; * be inclusive to other faculties, schools, and disciplines, who may want to attract students for relevant research projects, i.e., do not limit the program or your students to only biomedical related research, * clarify how different schools, research groups, centres, or institutes can attract students to work on projects or undertake a concurrent MBBS-Masters. Engage personally whenever possible with Centre and Institute Directors as well as individual researchers to emphasis the possible ‘pipeline’ to PhDs by attracting the best students into their research. Explain the pathway through early undergraduate (BSc) engagement, progressing to a concurrent MBBS-Masters at matriculation into medical school and later upgrading to a PhD. Invite research groups, centres, institutes, and individual researchers to speak to students about research opportunities in their respective laboratories or groups through research Expos and information evenings. Keep in contact with through regular email updates reminding researchers to send their potential projects to be posted on the website for students to peruse. Provide reminders of information sessions and research ‘Expos’. Start a database of student progression through their degree and of their publications, conference presentations, scholarship, and awards. Celebrate student achievements such as publications and awards widely in school and faculty newsletters and websites.

176


PhD. Various stages of approval and adherence to UQ policies were necessary to officially combine an undergraduate and a graduate degree and create a ‘concurrent MBBS-Masters program’. Introducing the concept and publicizing the program, its requirements, eligibility, and suitability to students and staff involved setting up several initiatives which are detailed in Table 1. The program officially commenced in January 2011.


Results Early indications of the CST’s impact suggest it is meeting the intention to attract and maintain a small elite percentage of each year’s cohort to approach 5% (12–15 per year). In three years, there are 42 enrolled MBBS-Masters candidates with the majority (90%) upgrading to a PhD at their first candidature milestone. Student research represents 33 different research areas and over 25 research groups, centres, and

institutes across UQ and internationally in New Zealand, USA, and UK. The preferred entry point into the concurrent MBBS-Masters is at commencement of year 2, after year 1 grades can be assessed. It is clear that the MBBS is the priority and a minimum grade point average (GPA) to apply for and be maintained throughout the program is required. The Masters is done part time alongside the full time MBBS with a minimum of two and maximum of three years to complete. While there is no requirement to complete both degrees together the aim is for candidates’ to make sufficient progress on their research in order to complete the Masters in conjunction with or very close to graduating their MBBS. Entry into the Concurrent MBBS-Masters involves two phases. The first phase is dictated by the UQSOM. Every interested and eligible student must seek permission to apply for the Masters degree. The second phase is dictated by the Graduate School who will assess each applicant, as any other, for approval to enroll in the Masters. Once enrolled, students

Table 2. Current demographics and academic details of concurrent MBBS/Masters candidates.

Sex Male Female

24–57% 18–43%

Age group (years) 21–24 25–29 30–34

7–15% 24–58% 11–26%

Relationship status Married/partnered Single

26–63% 15–36%

Domestic/international student Domestic International

36–85% 6–14%

Current year MBBS or Intern postgraduate year (PGY) MBBS year 2 MBBS year 3 MBBS year 4 PGY1 PGY2 University postgraduate scholarships awarded

12–29% 12–29% 10–24% 5–12% 3–7% 32–76%

Candidature progression Number confirmed (completed at least one year of Masters) Of those confirmed – number upgraded to PhD

18 12–67%

Early research output: Journal articles published or accepted in print while in the MBBS Conference abstracts and presentations while in the MBBS Research specific awards while in the MBBS Novice research grants (various external schemes)

40 36 10 4

How would you describe your interest in research? Equal to your interest in medicine Less than your interest in medicine Greater than your interest in medicine

35–84% 7–16% None

What percentage of your career do you envision involved in research? 25% 50% 75% I have no intention of being involved in any more research

31–74% 11–26% None None

Thinking about why you chose to do the Concurrent MBBS/Masters, which reason is most applicable to you? Strong desire to incorporate research into my medical career 18–43% Strong interest in developing my research skills 8–19% Improve my chances of getting into my preferred registration 7–17% Strong interest in my particular research area 5–12% Interest in an academic career 4–9%

177



may begin their Masters research on a flexible part time basis alongside all the full time requirements of the MBBS. Students’ RHD progression is monitored through the Graduate School’s Milestone system which helps to ensure quality monitoring of supervision and student progression throughout the research degree. Importantly 76% (n ¼ 32) of students have won extremely competitive university-wide postgraduate scholarships. This success attests to the quality of the students chosen to enroll. Student progression through the three required RHD ‘Milestones’ has also been satisfactory with all students successfully completing their first Milestone (approximately one year into the part time Masters). Furthermore, of the students who have reached their first Milestone, 67% (n ¼ 12) have upgraded to PhDs. Upgrading to a PhD means that these students have made exceptional progress in their Masters research and have enhanced their project to the PhD level. These students continue their, now PhD, research part time with the understanding that completion of the PhD will occur during their early post-graduate medical training. The high percentage of students moving up to a PhD is encouraging because it shows a level of commitment necessary to complete the degree and moves us closer to our aim of training more clinician scientists.

The students’ perspective Introduction of the Concurrent MBBS-Masters was immediately popular among students for two main reasons: (1) it allows able students to obtain a research higher degree without extending their medical training and (2) ensures that their competitiveness in the job market after graduation is high through enhancing their CV with a research higher degree and inevitable journal publications. In an effort to get an early snap shot of the current cohort of students, a survey was administered asking about future research plans and personal reasons for entering the CST. Table 2 shows their demographic characteristics and responses regarding personal perceptions of and reasons for undertaking the CST. Students choose their own area of research and often devise their own project. Table 3 lists the areas of research represented across the CST and indicates the variety available. A key consideration is for the project’s research design to have a degree of flexibility and additionally the potential to be broadened to a PhD. Projects which are strictly laboratory based or heavily reliant on clinical time with patients are not recommended because of competing time commitments with the full time medical degree. For example, public health and epidemiological research are ideal projects for the concurrent MBBS-Masters because they often involve secondary data analysis which has a flexible element and less rigid timeframes for its collection. Similarly patient audits can be scoped appropriately for a Masters. This flexibility is important because we recognize that progression on their research project often slows or is interrupted during busy periods typically in conjunction with certain clinical rotations and exams. 178

Table 3. Research areas represented across concurrent MBBS-Masters projects.

Surgery Pediatric robotics Orthopedic trauma surgery Cardiac Cerebral palsy and rehabilitation Neuroimaging Cancer Pancreatic Skin Urology Lung cancer Mesothelioma Head and neck Medical engineering research BIVACOR artificial heart Hemocapatability, blood transfusion Neuroscience Brain imaging Molecular and cellular neurobiology Synaptic plasticity Cortical development and axon guidance Population health Epidemiology Burns, trauma and critical care Pharmacokinetics Lung and thoracic research COPD Immunology/clinical immunology Emergency medicine Cardiology Pharmacy Ophthalmology Biomedical sciences Perinatal health Obstetrics and gynecology Dermatology Primary care Psychiatry Exercise physiology Pharmacy Medical education

Early outcomes Research output measured by publication among our students has been exemplary in the three years since inception of the CST. An underestimation, given the lag time in publication, shows over 40 peers reviewed publications, 36 conference abstracts/presentations, 10 research specific awards, and four novice research grants produced by the current cohort. These figures indicate that the CST is providing students with the stimulation and opportunities to pursue research and produce research output before graduation. This output bodes well for the future, because as Reinders et al. (2005) showed, students who gained research training while in medical school had a publication output after graduation of 4:1 over students without medical school research experience.

Getting it right – Students and advisors Certainly choosing the ‘right’ student is paramount to success and early results indicate that the most academically outstanding students progress with little or no difficulty and cope with



Figure 2. Schematic representation of the options and timeframe of the Clinician Scientist Track. Over time, the CST aims to fulfill the spectrum of research training which ideally sees a promising student ‘groomed’ secondary school and/or a Bachelor degree through to a PhD. The SOM already participates in High School scientist partnership programs which place outstanding year 12 science students in SOM research groups over their final year. Several of these students maintain a research focus throughout their Bachelor degree through summer research placements, an Honours year, and casual research work experience. On matriculation into the medical program, eligible students may enroll in the Masters at the start of Y2 and complete the degree in part time alongside their full time MBBS. Alternatively in Y3 and after Confirmation of their Masters (approximately one year into the degree), students may upgrade to a PhD. These PhD candidates continue their research on a part time basis alongside their medical training and aim to complete in another two to three years depending on how far advanced their research was when they upgraded from the Masters. The aim is to complete the PhD before speciality registrar training.

the additional workload and responsibly. While a high capacity for academic achievement has been a consistent indicator of a student’s successful progression in the MastersMBBS, equally important are high levels of basic traits such as organization, communication, commitment, and selfdirectedness. These traits should be evident from the start because the onus of finding the right project and match with an advisor is driven by the student. In this regard, the match with a principal advisor is equally vital to student success as is building trust and support amongst researchers and the university research community. An initial misconception we found among some researchers was that Master-MBBS students were allowed dedicated time out of their MBBS curriculum to spend on their research. Unfortunately this is not true and it is made very clear that his part-time Masters is done ‘alongside’ the full time MBBS. This stipulation has actually been positive as many researchers are re-thinking ways to strategically involve a medical student in sub-projects of large ongoing research or entrust dormant projects/data to these capable students for completion. Cherishing the ‘champions’ of the CST who achieve successful outcomes with their students helps to reinforce confidence and perpetuates not only their interest and involvement but also serves as a good advertisement of the program to research colleagues across UQ. In this regard, a strong ‘selling point’ to UQ researchers is the potential benefits of supervising a RHD. Every supervisor must fulfill the Graduate School’s requirements for supervising RHD students and this is often the impetus which drives researchers to become involved in an academic career. This extends to the opportunities available as an RHD supervisor to increase their professional development through the Graduate

School’s supervisor’s skills program. Additionally, the potential for international research collaboration through joint RHD student supervision has already been realized between UQ supervisors and their counterparts in the USA, UK, and New Zealand.

Discussion Over time, the CST aims to fulfill the spectrum of research training which ideally sees a promising student ‘groomed’ from secondary school and/or a Bachelor degree via summer research programs and short-term immersive placements, on through to an MBBS-PhD. Figure 2 provides a schematic representation of the CST and approximate timeframe. We have highlighted several obvious and previously reported advantages of RHD training for medical students. However, the main point is to highlight a model which is flexible, achievable, and attractive to students and staff. A key driver for the CST was establishing a ‘teaching-research nexus’. We use the term in its broadest sense – that of relationships which are dependent on contextual factors (Neumann 1994). The context is our research intensive University. Therefore, the relationship we sought meant capitalizing on that wealth of research expertise and opportunity to combine with our medical teaching environment. This relationship may be a relevant concept for other research intensive institutions where large amounts of funding are directed toward research – but there is little obvious flow on to teaching. A further consideration for medical education is how to enrich this nexus and incorporate the clinical component. In other words, a ‘teaching-research-clinical nexus’ would be most appropriate for nurturing future clinician scientists.

179



The key catalyst to solving this dilemma was the students themselves. Medical students are highly preferred as RHD students by clinical and basic science researchers because they facilitate translational research. Students bring the clinical element to basic research and bridge the gap to translational work. Similarly clinical researchers also make that connection to basic research and see students as an opportunity to undertake often a backlog of important investigative research which they themselves have no time to do. The result is an increase in research capital for clinicians and students. Stimulating interest and subsequently achieving trust from clinicians and researchers is an ongoing process. However, in three years, this initiative has raised the profile of student research across the School and University institutes and centres that previously had little engagement with medical students. Interestingly, the overall profile of research has heightened among the entire student body. Increasing numbers of students who are not eligible, or have no interest in doing the MBBS-Masters are seeking volunteer/casual opportunities simply to gain research experience. A dedicated website was developed to facilitate a wide range of research opportunities for these students representing a broad continuum of interest and experience. We have described the rationale for the CST which corroborates the wealth of literature on the importance of rejuvenating and maintaining the ethos of the Clinician Scientist. It has provided a new and flexible way to provide the most outstanding students an early start to their research career. To date only surrogate endpoints have been realized, i.e., student publications and CV enhancement. It is too early to speculate what impact the program may have on students maintaining their research momentum alongside competing responsibilities in post-graduate and speciality training years. However, early indications are that the CST is connecting students with early research careers in efforts to rejuvenate the clinician scientist.

Notes on contributors DIANN ELEY MSc, PhD, is an Associate Professor and a MBBS Research Coordinator in the School of Medicine, The University of Queensland. Her research interests focus on medical education, research training, rural health/workforce, and personality and behaviour associated with well being, and progression through medical training. DAVID WILKINSON, BSc(H), MBChB, MSc, MD, PhD, DSc, FRCP, FRACGP, FAFPHM, was Dean of Medicine at The University of Queensland when this program was conceived and initiated. He continues to have interests in strategic, and ‘big picture’ aspects of medical education, including in transnational programs, global benchmarking of learning outcomes, and novel structures to medical degrees.

Declaration of interest: The authors report that they have no declaration of interest.

References Ahn J, Watt CD, Man LX, Greeley W, Shea JA. 2007. Educating future leaders of medical research: Analysis of student opinions and goals from the MD–PhD SAGE (Students’ Attitudes, Goals, and Education) Survey. Acad Med 82:633–645.

180

Andriole DA, Whelan AJ, Jeffe DB. 2008. Characteristics and career intentions of the emerging MD/PhD workforce. JAMA 300:1165–1173. Bell J. 2003. Resuscitating clinical research in the United Kingdom. Br Med J 327:1041–1043. Brass LF, Akbas MH, Burnley LD, Engman DM, Wiley CA, Andersen OS. 2010. Are MD–PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD–PhD programs. Acad Med 85: 692–701. Collins JP, Farish S, Mccalman KS, Mccoll GJ. 2010. A mandatory intercalated degree programme: Revitalising and enhancing academic and evidence-based medicine. Med Teach 32:e541–e546. Cox TM, Brimicombe J, Wood DF, Peters DK. 2012. The Cambridge Bachelor of Medicine (MB). Doctor of Philosophy (PhD): Graduate outcomes of the first MB/PhD programme in the UK. Clin Med 12: 530–534. Griffin MF, Hindocha S. 2011. Publication practices of medical students at British medical schools: Experience, attitudes and barriers to publish. Med Teach 33:e1–e8. Hunskaar S, Breivik J, Siebke M, Tommeras K, Figenschau K, Hansen JB. 2009. Evaluation of Medical Student Research Programme in Norwegian medical schools. A survey of students and supervisors. BMC Med Educ 9:43. Laskowitz D, Drucker RP, Parsonnet J, Cross PC, Gesundheith N. 2010. Engaging students in dedicated research and scholarship during medical school: The long-term experience at Duke and Stanford. Acad Med 85:419–428. Lemoine NR. 2008. The clinician–scientist: A rare breed under threat in a hostile environment. Dis Model Mech 1:12–14. Ley TJ, Rosenberg LE. 2005. The physician–scientist career pipeline in 2005 build it, and they will come. JAMA 294:1343–1351. Lipner RS, Lelieveld C, Holmboe ES. 2012. Performance of physicians trained through the research pathway in internal medicine. Acad Med 87:1594–1599. Murdoch-Eaton D, Drewery S, Elton S, Emmerson C, Marshall M, Smith JA, Stark P, Whittle S. 2010. What do medical students understand by research skills? Identifying research opportunities within undergraduate projects. Med Teach 32:3152—3160. Neumann R. 1994. The teaching-research nexus: Applying a framework to university students’ learning experiences. Eur J Educ 29: 323–338. Nicholson JN, Cleland J, Lemon J, Galley HF. 2010. Why medical students choose not to carry out an intercalated BSc: A questionnaire study. BMC Educ 10:25. NIH NIGMS: National Institutes of Health, National Institute of General Medical Sciences. 2013. Medical scientist training program. [Accessed 8 September 2013] Available from http://www.nigms.nih.gov/Training/ InstPredoc/PredocOverview-MSTP.htm. Nikkar-Esfahani A, Jamjoom AB, Fitzgerald JEF. 2012. Extracurricular participation in research and audit by medical student: Opportunities, obstacles, motivation and outcomes. Med Teach 34:e317–e324. doi: 10.3109/0142159X.2012.670324. Reinders JJ, Kropmans TJB, Cohen-Schotanus J. 2005. Extracurricular research experience of medical students and their scientific output after graduation. Med Educ 39:237. doi: 10.1111/j.1365-2929.2004.02078.x. Roberts SF, Fischoff MA, Sakowski SA. 2012. Transforming science into medicine: How clinician-scientists can build bridges across research’s ‘valley of death’. Acad Med 87:266–270. Siemens RD, Punnen S, Wong J, Kanji N. 2010. A survey of the attitudes towards research in medical school. BMC Med Educ 10:4. Stewart GW. 2012. An MB-PhD programme in the UK: The UCL experience. Clin Med 12:526–529. Tooke J, Wass J. 2013. Nurturing tomorrow’s clinician scientists. The Lancet. 381(Suppl 1):S1–S2. doi: 10.1016/S0140-6736(13)60444-4. Whitcomb ME. 2007. The need to restructure MD–PhD training. Acad Med 82:623–624. Yap KK. 2012. The clinician–scientist: Uniquely poised to integrate science and medicine. Aust Med Stud J 3:10–11.