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To recruit and train the next generations of pediatric clinician-scientists, the American Pediatric Society (APS) and Society for Pediatric Research (SPR) initiated a program in 1991 to support medical students with interests in research and pediatrics to conduct research at institutions other than their respective medical schools. Since 1991, the APS-SPR Medical Student Research Program (MSRP) has funded 732 of 2209 applicants from 132 U.S. or Canadian medical schools for 8 to 12 weeks of research under the direction of experienced investigators. PubMed-attributable publications tabulated in 2001 for MSRP applicants through 2000 indicated that participants had published more actively than had non-participant applicants. Male non-participants exhibited greater publication activities than did female non-participants, but female and male participants published equally. Of all MSRP participants between 1991 and 1996, as of 2008, 36% were in pediatrics, and a remarkable 29% were in academic pediatrics.
Clinician-scientists are important to progress in biomedical research, because clinician-investigators can provide diversities of experience and training that are particularly crucial in biomedical research needed for continued improvements in clinical care (1-3). Differences in cultural backgrounds and ethnicities also bring diversity to the problems facing health care development and delivery. Minority medical school graduates are more likely to practice in medically underserved communities than are non-minority medical graduates, and minority clinician-scientists are likely to be more active in investigating problems that affect patients who would otherwise remain underrepresented in the biomedical research enterprise (4-7).
To encourage more medical students, especially those from underrepresented racial and ethnic groups, to consider research in their career paths, increases in exposure to and training in research are needed for medical students and postgraduate trainees. Publication and research experience prior to completion of medical school are important correlates to subsequent academic careers (8), and publication prior to completion of medical school was the strongest correlate with entrance into academic careers.
The American Pediatric Society (APS) – Society for Pediatric Research (SPR) Medical Student Research Program (MSRP) was initiated in 1991 and designed to address the challenges in encouraging medical students to pursue careers in academic medicine. The MSRP accepts applications from medical students, typically in their first or second years of medical school, and offers 8 to 12 weeks of support for training in research laboratories not associated with the applicants' medical schools. Funds are provided to help defray expenses of living in a different city. Participation by underrepresented minority students is encouraged, and such students are recruited actively.
The present report is not the result of a blinded, randomized trial of the effects of participation, but represents an effort to assess the impact of the MSRP, using the most objective approaches and criteria available.
In 2001, we evaluated all of the applicants to the MSRP from 1991 through 2000. The applicants' data on year of application, participation, gender, self-identified ethnicity, medical school attended, and applicant's lab supervisor were obtained from the database maintained by APS-SPR. During 1991-2000, 28 applicants who were offered support by the MSRP chose not to participate, and three applicants who were not selected for support were funded by the respective lab in which the student worked. Gender was requested for applicants after 1992. For analysis of data from applicants in 1991 and 1992, gender was assigned for reasonably gender-specific names but was left unassigned for names not regarded as sufficiently gender-specific. Self-identified race or ethnicity was requested for applicants from 1993 forward. Applicants from 1991 or 1992, applicants who did not participate in 1993, and the 28 applicants from 1994-2000 who did not self-identify with a racial or ethnic group were entered as None Listed. Data from the two applicants who identified themselves with two different race/ethnic groups were included with both groups.
Evidence for publications was sought for each applicant, using PubMed and a systematic strategy with the student's name and sequential Boolean refinements, using the applicant's medical school, country, MSRP mentor's name and institution, and the state of the applicant's medical school, in addition to other relevant information were obtained from the APS-SPR data base. The manner in which these parameters were employed in search refinement is provided in supplementary material available online at www.pedresearch.org.
MSRP participants during 1991 through 1996 were assessed similarly in 2008, using the systematic PubMed strategy described above. Participants during this period also were investigated by combined PubMed and Google searches, to identify present professional positions, which were categorized as pediatric or non-pediatric and academic or non-academic. Non-participant applicants were not examined in these more recent assessments.
Nominal data were assessed statistically by Chi-squared tests. Parametric data were assessed with independent samples t-tests, one-way ANOVA with Student-Newman-Keuls tests post hoc, or with linear regression analyses, with differences noted at P < 0.05.
Of the applicants who chose to self-identify with African-American, Asian, Caucasian, or Hispanic races or ethnicities, the participation percentages over the period from 1991-2000 were between 31 and 36%, evidencing uniform participation (P=0.283 by Chi-Squared analysis) across these four racial or ethnic groups (Table 1). Pacific Islanders' participation of 60% was associated with small numbers of applicants (n = 15) during this period. The Pacific Islander ethnic group was not listed in the forms until 1997. At the time of the 2001 comparisons, no applicants had self-identified as Native American, even though this option had been included since 1993. For the 249 applicants identified in the 2001 data as None Listed, 220 (88.4%) were from 1991-1993, during which time race/ethnicity identification was not requested from the participants (1991-1992) or from the non-participants (1991-1993). The additional 29 individuals included in the None Listed category from 1994-2000 either declined to self-identify as a member of a racial or ethnic group or may have overlooked this part of the application.
The 2001 cross-sectional comparison showed that the percentages of applicants for whom PubMed searches provided evidence of subsequent publication were higher for the MSRP participants than for non-participants (Figure 1A). The percentages of former applicants who had published at least one PubMed-retrievable paper increased with time for the participants (P<0.001), but not for the non-participant applicants (P=0.182).
African-American, Asian, Caucasian, and Hispanic participants were more likely to have published one or more papers than were non-participants of the same racial or ethnic group (P = 0.033, 0.003, 0.003, and 0.008, respectively), with ratios ranging from 1.6 for Asians to 4.0 for African-Americans (Figure 1B). Among students with no race or ethnicity identified, the publication rates by participants and non-participants were not different (P=0.075). The publication percents of Pacific Islanders were not different (P=0.925), but this comparison was based on small sample sizes (9 and 6, respectively).
Overall, MSRP participants were 79% more likely to have published than were non-participants (P<0.0005). Female participants were twice as likely to have published (Figure 2A), as were female non-participants (P<0.0005), whereas male MSRP participants were associated with a 65% greater probability of subsequent publication than male non-participants (P=0.008). The publication percents for male and female non-participants were not different (P=0.090), nor were publication percents between male and female participants (P=0.956).
The numbers of publications per person were higher (P=0.007) for participants than for non-participants (Figure 2B). The average numbers of publications for female participants were greater (P<0.0005) than for female non-participants, whereas the same comparison between participant and non-participant males does not indicate differences (P=0.089). Comparisons between males and females, among participant and non-participant applicants, indicate greater numbers of publications per applicant by non-participant males than by non-participant females (P=0.004), whereas a similar gender disparity is not observed among participants (P=0.196).
Although MSRP participation was not associated with differences (P=0.069) in the probability that a student would publish one or more first author papers (Figure 2C), a difference between all male and female applicants is indicated (P=0.033). This difference in percentage of applicants who subsequently published at least one first author paper is driven by the gender difference in first author publications by the non-participants, with male non-participants over three times as likely to have published at least one first author paper than female non-participants (P<0.0005). This gender effect in percentages of first author publications was not observed among MSRP participants (P=0.313), suggesting a unique contribution of MSRP participation to the research career development of female medical students.
By 2008, most of the students, who participated in the MSRP between 1991-1996, had completed their training and made career decisions that would provide an informative assessment of their professional intentions and initial goals. Assessment by MSRP year revealed that between 12 and 28% of the participants between 1991 and 1996 had published one or more papers with their respective MSRP mentors (Figure 3A); however, the total publication rates for these students ranged between 40 and 65%.
Focused, systematic search strategies provided present status data for slightly more than 94% of the students from MSRP years 1991-1996. Between 26 and 47% of the total participants in each year were in pediatrics, roughly two to three times the national averages for medical school graduates. More remarkably, from 23 to 45% of the total participants for each year were in academic pediatric positions (Figure 3B).
The use of non-participant applicants as controls for the evaluation of the possible effects of the MSRP on student research career development has limitations. The most obvious limitation is the extent to which selection bias results in two groups that are not equal at the outset, as would be needed for objective assessments of the benefits of MSRP participation. The MSRP was never intended to be a randomized control trial to test hypotheses regarding the social psychology of research training. If the present results are dominated by effective selection of students that are more capable and/or more dedicated to academic careers, at least the MSRP has invested in the research training of a promising group of clinician-scientists.
Publication was chosen as the primary early indicator of academic career progression, because early publication is the single strongest correlate with pursuit of a career in academic medicine (8). PubMed-retrievable publications were chosen for the present evaluations, rather than questionnaire-based methods, to collect objective data and avoid potential response biases between participant and non-participant students. Acquisition of independent grant funding and promotion in academic rank would be stronger indicators of academic career progression by clinician-scientists, but these milestones will require longitudinal studies to collect the appropriate data.
Within the limitations provided by the methods used, the greater publication rates observed among participants than non-participants suggest that the MSRP selection process effectively identifies promising students and/or MSRP participation itself has beneficial effects. Because most students applied to the MSRP during their first year of medical school, with the research experience usually occurring during the summer between the first and second years of medical school, the increase in publication percentages over time (Figure 1) suggests continued progression of academic career development in the MSRP participants, but not in non-participant applicants.
The markedly greater publication rates among African-American and Hispanic participants than among their respective non-participant applicants (Figure 1B), suggest that the MSRP may be having considerable impact among underrepresented minorities in recruitment, encouragement, and training for careers as clinician-scientists. Similar successes have been observed with the Stanford Medical Youth Science Program, which focuses on encouraging and mentoring socioeconomically underprivileged high school students to enter scientifically related fields (9).
Although not an original focus of the MSRP, the unanticipated gap between male and female non-participants for first author publications (Figure 2C) suggests a gender bias in academic career development that has received limited attention (10). The implications of the gender-based differences in publication rates by non-participants have not been established, but the differences in the percentages of male and female non-participants with one or more first author publications are striking. Conversely, the absence of gender-based differences in first author publications by the participants strongly suggests that the MSRP has positive effects on academic career development among female medical students. The possibility that the data on first author publications could be attributed to selection bias is highly unlikely, because this interpretation would require that the steering committee was somehow more able to distinguish capable and dedicated applicants among females than among males.
The rates of publication with their respective MSRP research mentors by the students from 1991 through 1996 are modest, ranging between 12 and 28% for each year (Figure 3A). Two to three months is a limited period of time for completion of a research project, even for talented and committed students in productive labs. However, the longer-term publication frequencies of these students, ranging between 37 and 65% for these MSRP years, suggest substantive engagement of these students in research and academics. The choice of a career in pediatrics by 26 to 39% of these students (Figure 3B), at two to three times the national average of 13%, for graduates of U.S. medical schools (11), is reasonably attributable to selection bias for pre-existing interests in pediatrics, but contributions from exposure in the MSRP are not excluded.
Solomon et al. reported that medical students formerly participating in summer research programs at the University of Tennessee College of Medicine and Vanderbilt University School of Medicine exhibited high rates of publication and of current participation in academic medicine (12). However, the data reported by Solomon were based on questionnaire replies, with response rates in the range of 30%, and selection bias in responses by the former students would not be unexpected.
The vast majority of the former MSRP students who are in pediatrics are in academic pediatric positions (Figure 3B), which is most remarkable. The data presented in Figure 3B for students from 1991-1996 in academic pediatric positions in 2008 are not percentages of students in pediatrics, but of all students who participated in the MSRP in the years indicated. The data represent rates of entry into academic pediatrics that are roughly ten times the national averages for U.S. medical school graduates (1).
The MSRP clearly has been successful in attracting large numbers of highly qualified medical student applicants, particularly among women and members of underrepresented racial and ethnic groups. The higher rates of publication by participants than by non-participant applicants suggest that the selection process has been effective in identifying the more promising students and/or MSRP participation has contributed to the career development of the students. The most encouraging data supporting the contributions of this MSRP to the stated goal of recruitment and training of pediatric clinician-investigators are the remarkable numbers of former students who participated in the MSRP from 1991 through 1996 who have entered careers in academic pediatrics.
Special thanks are due to Ms. Barbara Anagnostelis, whose tireless efforts in managing the many details essential to the operation of the program have been deeply appreciated by all those involved.
Financial Support: The support of this Program by APS-SPR, HD007446, and the individual institutions and investigators is gratefully recognized.
This article contains supplemental material available online at www.pedresearch.org.