Things I Wish I knew as a Medical Student: reflections from a research pro

Below we hear from Dr. Rob Green, researcher extraordinaire, about medical student research He was featured earlier this week in “Guess Who? Canadian EM Research Edition” but today reflects on what he wish he knew as a student. – EP

After years of training and subsequently developing an academic position in Emergency Medicine, Critical Care Medicine and Trauma in Halifax, I have been asked by many students for hints and tips for successful research projects. Learning to perform research well can be a daunting task, especially while you’re busy learning about medicine as a medical student and resident. Like everything else in life, research projects often don’t go the way you’d planned.

My hope is that we can learn from experience. So, I’ve come up with a list of things that I wish I would have known back when I was a student:

1. What makes a good research project for students?
The best research projects are ones that you are passionate about. Sometimes research can be a slog and keeping ones attention focused throughout a project can be difficult. Finding a research project that really speaks to you will make it much easier to stay engaged and ultimately share your findings with others.

One of my personal research interests is describing the importance of post-intubation hypotension in critically ill patients in the emergency department. This is an area that became very important to me when I was a junior resident. I clearly recall intubating patients in the ICU in the middle of the night by myself and then scrambling to reverse the hypotension that seems to occur immediately after. I remember a repeated pattern after many intubations and decided in my mind that this was a problem that needed to be solved. I am now actively engaged in researching post-intubation hypotension (for > 10 years!) and what factors are associated with poor patient outcomes, and I truly believe my enthusiasm will make a difference in patient care.

2. Finding an experienced research mentor is important
What I needed as a student and a junior resident was a connection with a mentor that enthusiastically supported my research desires. I believe a mentor should challenge a student on all aspects of research, pointing out both the positive and negative. Mentors should be willing to discuss research ideas, and they should be knowledgeable on what types of projects are feasible for any given student. Unfortunately, with emergency medicine being a relatively young field in Canada, there aren’t an abundance of expert Canadian EM researchers. Despite this, often an “expert” is not essential – yet an engaged mentor is. Choose wisely.

3. Research training is under appreciated
I was never steered toward specific training and research during my medical school training, and I regret persusing advanced training in research until after I was an attending physician. I have recommended to many students that the best time to do all your training is at the start of your career, specifically during your medical school and residency.

It is incredible how knowledge gained early in a career translates into clarity and research productivity by mid and late career. By not developing a strong foundation in research methodology at an early point in one’s career, I believe it makes it much more difficult to achieve optimal research success, even in the most gifted researchers. Many options are available both within University curriculums and via long distance learning programs, and I encourage all students with any research endeavors to thoroughly assess such programs for their specific needs.

4. Watch the stars perform
I learned a heck of a lot about resuscitation just by watching experts from various specialties apply their trade during my training years. The same potential for gaining experience stands for research. We have some excellent research stars across Canada. My suggestion for students (and one that I have done since I was a medical student) is to keep your eye on the stars of research.

As an example, an early influence of mine was Dr. Grant Innes, the Founding Editor-in-Chief of the Canadian Journal of Emergency Medicine (CJEM), although he likely would have no knowledge of this. I clearly recall his lecture at a CAEP conference on “How to publish”, and realized that there are experienced researchers that “are doing it the right way”. Since then, I’ve followed the careers of many colleagues across Canada closely and have learned invaluable lessons with an appreciation of the heights that an EM researcher in Canada can achieve.

5. Silos don’t work
Regrettably, these days a lot of research is performed in silos, not only between specialties but within specialties. Emergency Medicine in Canada is a small group. In order to be successful, collaboration is required. The model that I’ve found to be most successful is that where a group of researchers work together through all stages of a research project. The benefits are tremendous: sharing of ideas, sharing of workload, sharing of resources, collaborating on abstracts and manuscripts, etc. Research productivity exponentially increases with collaborations. The Canadian Critical Care Trials Group is a world class example of this. You can never have too many friends in the research community. Make sure to take advantages of social media tools such as ResearchGate and Twitter to expand your network.

6. Don’t be too critical
One of my pet peeves has always been going to journal club and seeing the research of others being destroyed by overly harsh criticisms. While we are understandably trained to critically evaluate research findings and recognize what constitutes excellent research, I believe it is equally important to determine why research was performed in such a manner and how it may have been improved. Perhaps a prospective randomized control study is not always appropriate (or possible) in every given situation. Perhaps a case report is actually useful in some instances (although not many).

Certainly with every year of experience that I’ve gained, I find it easier to commiserate with most of the authors that I review. In fact, I have never seen a flawless study, and I don’t know if it’s even possible to perform a study without any flaws. Considering the faults are important, but the positives are also equally important to consider. We can all learn a lot from almost any study.

7. Coming up with a research idea is the easy part – finishing is the tough part
Part of being a researcher is developing and cultivating a creative thought process. The ability to come up with a unique research idea often entails looking at problems from a different perspective.

However, envisioning and formulating a worthwhile research question is just the easy part. The hard part is actually transforming an idea into a feasible and achievable research project. Once the initial research question has been determined, a host of issues arise including the type of study design to pursue, whether a systematic review should be performed prior to any analysis of patient data, how long a project will take to complete, what resources will be required to complete the study, where an abstract should be submitted, what journal to target for the manuscript, etc.

Many times, the initial research question is only the first step of a long process that leads to progressively deeper and more valuable questions that beg to be addressed and resolved. As any researcher will tell you, completing the project and publishing the study is the most difficult. Students need to be aware of this – and prepare for more than the excitement of coming up with a great idea. Supervisors often get frustrated by mentoring students whose ideas are not seen through to completion.

8. Research may be hard… but rewarding
When I look at research across Canada, it does strike me that there’s an imbalance between excellent educators and excellent researchers. Why is that? While this was not clear to me as a student, now it is: research is difficult!

Many of us are natural educators because that is something we have been exposed to since childhood every day right through to the end of training (and beyond). However, research is a different beast altogether, often quite foreign to many students and physicians alike. However, for those that pursue their research endeavours, research can be extremely rewarding.

Successful research studies and publications positively impact our understanding of critical illness and trauma, how EM is being performed, and how EM should be performed – this is how we move forward. Advances in EM research have tremendous potential to improve the standards of patient care for the benefit of all. And, it is a thrill like no other when you finally publish…

9. Learn from rejection
I remember my first manuscript that was rejected. I couldn’t believe it. How could these reviewers not appreciate the “greatness” of my PGY1 research project? How dare they not understand? Unfortunately, this is normal in research.

As any editor of CJEM will tell you, reviewers come from all different walks of life, they all have different areas of expertise and their own past experiences. Rejection of quality research happens all the time. In fact, there are well documented cases of research being rejected in a lesser journal and then published in a more prestigious journal later on. Often times, the quality of one’s research appears to be in the eyes of the beholder.

Students need to realize that rejection is an inevitable part of research and simply accept it if and when it happens. It’s not terrible; it’s not bad at all. It is an opportunity for improvement and for clarification. Having had one of my manuscripts recently rejected in the last few days, I can grit my teeth and let you know that while it’s not pleasant to have your work grinded up by others, once you detach yourself emotionally from the process it becomes much easier to get to the next step: moving on.

10. You can’t predict who’s going to be a good researcher
I’ve seen it all. I’ve seen excellent students with PhD research backgrounds enter medical school with the promise and the intention of becoming a great researcher and go on to have short-lived research careers. I’ve also seen the opposite: the student who comes into emergency medicine with no real expectations at all and then becomes so engaged in research that they take all the necessary steps and become excellent researchers.

My point, you can never predict who will have a successful research career – so give it a try! While I believe that much of one’s success in research is likely to be determined by how their personal experience aligns with the points outlined above, even then you cannot easily predict who will succeed. In the end, people are who they are; educators are educators, researchers are researchers, some do both, some do neither. Above all, your personal drive and determination will define your life and career.

My hope is that others can learn from my experience. We need researchers in Canadian emergency medicine, and maybe you are one of them!!!

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