Published online May 1, 2006
PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1818-1822 (doi:10.1542/peds.2005-1249)

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EXPERIENCE AND REASON

The Boston Marathon Study: A Novel Approach to Research During Residency

Andrew Y. Shin, MD^a, Christopher S.D. Almond, MD, MPH^a, Rebekah C. Mannix, MD^a, Christine N. Duncan, MD^a, Mary Beth F. Son, MD^a, Heather M. McLauchlan, MD^a, Usama B. Kanaan, MD^a, Jennifer M. Litzow, MD^a, Pearl S. Riney, MD^a, Cameron C. Trenor, III, MD^a, Elizabeth B. Fortescue, MD^a, Robert J. Vinci, MD^b, David S. Greenes, MD^a on behalf of the resident physicians from the Boston Combined Residency Program

^a Department of Medicine, Children's Hospital Boston, Boston, Massachusetts
^b Department of Pediatrics, Boston Medical Center, Boston, Massachusetts

	ABSTRACT

TOP ABSTRACT THE PROJECT STUDY DESIGN DISCUSSION CONCLUSIONS REFERENCES

 
Resident physicians from a pediatric academic training program developed a hospital-wide research project in an effort to enhance their residency research experience. In this model, residents themselves assumed primary responsibility for each stage of a large prospective clinical research study. The project, which was integrated successfully into the residency program, enabled a large group of residents, with mentorship from a dedicated faculty member, to benefit from a structured clinical research experience while providing the flexibility necessary to meet the demands of a busy residency curriculum. Careful topic selection with a well-defined end point, faculty involvement, resident collegiality, and institutional support were factors identified by study leaders as central to the success of this model.

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Key Words: research • resident education/training • residency/internship

Participation in research during residency training is recognized as an important component of physician education.^1–9 Although many residents express interest in pursuing research during residency, rates of participation tend to be low, and the quality of the research experience can vary greatly.^4,10 Lack of time, difficulty in finding a suitable topic, and unavailability of appropriate mentorship have been identified as important obstacles to research for residents pursuing residency full-time.^1,4,11–17 Here we describe a novel approach to resident research in which a prospective research study is conceived, designed, implemented, and completed by a large group of residents working together. Careful topic selection, an atmosphere of collaboration among residents, and faculty support were identified by study leaders as key factors to the success of the project. The rationale, advantages, and limitations of this research model are discussed.

	THE PROJECT

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Conception and Initial Organization
In the fall of 2001, a small group of residents at 2 teaching hospitals in Boston, Massachusetts, developed an idea for a residency research project. With guidance from an associate program director, the group developed a research protocol for a prospective study designed to investigate the incidence and risk factors for hyponatremia, troponin elevation, and menstrual dysfunction among runners in the Boston Marathon. The idea for the study stemmed initially from a patient treated by the housestaff who had developed severe hyponatremia during the New York-to-Boston AIDS ride. After review of the literature and additional discussions with the faculty, the residents formulated a set of research questions and a suitable and convenient study population in which to test their hypotheses.

The 3 main objectives of the planning group were to (1) provide residents with a high-quality educational experience in clinical research, (2) make a meaningful contribution to the medical literature, and (3) cultivate a strong sense of unity and collegiality in the residency program through participation in a group project. The planning group became the steering committee for the study. The steering committee proposed their plans to the residency as a whole in an effort to involve as many residents as possible. The leading resident investigators formally applied for and were awarded funding from Children’s Hospital Boston General Clinical Research Center and the Kobrun Family Fund through the Department of Cardiology. Early in the planning stages, a tentative authorship list was assigned for each of 3 proposed manuscripts (based on hypotheses developed for each of the 3 primary study arms) in an effort to clarify expectations among all involved and to minimize the potential for discord as the work progressed.

	STUDY DESIGN

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As previously reported,¹⁸ marathon runners were recruited prospectively at an exposition 1 or 2 days before the Boston Marathon. The subjects completed a survey describing baseline demographic and training information and medical history. At the finish line, runners provided a blood sample and completed a questionnaire detailing information such as fluid consumption and symptoms experienced during and after the race. A prerace and postrace weight was recorded for each runner.

Resident Involvement and Organization
All 115 residents in the program were invited to participate in the project. Interested residents were asked to participate in 1 of several subcommittees (Table 1), which included (1) protocol development, (2) fundraising, (3) runner-subject recruitment, (4) runner and laboratory processing, (5) equipment setup and removal, (6) data analysis, (7) data safety monitoring, and (8) manuscript preparation. The lead investigators, with mentorship from the associate program director, took responsibility for the institutional review board's application and subsequent amendments. Open protocol-development meetings were held weekly to discuss and respond to feedback from hospital scientific and institutional review boards. These meetings included teaching sessions on the principles of study design and statistical analysis. In addition, residents were responsible for completing a required online training module before they could participate in the informed-consent process. Residents consulted freely with subspecialty faculty from emergency medicine, cardiology, nephrology, adolescent medicine, laboratory medicine, and endocrinology. However, final decisions regarding study design rested with the residents. Summaries of each meeting were circulated to ensure that participating residents who were unable to attend remained current with the study's progress.

View this table: [in this window] [in a new window]   TABLE 1 Boston Marathon Study Organization and Primary Challenges

 
Overall, a total of 76 of 115 residents participated (66% of the training program). Of these, 25 (33%) were postgraduate year (PGY)1 residents, 13 (17%) were PGY-2 residents, and 38 (50%) were PGY-3 residents; almost every PGY-3 resident participated in some aspect of the study. Most of the residents (58%) were women, which reflected the overall gender distribution of the program. There was no difference in participation on the basis of program track (categorical residents versus primary care residents). Nearly 3 dozen residents worked at the prerace research station approaching and enrolling >700 runners, and >50 residents (and nurses) worked at the postrace station drawing blood samples from nearly 500 runners. At peak operation, 24 phlebotomy stations operated simultaneously at the finish line. Residents with previous laboratory experience oversaw sample collection and handling (including centrifuging and freezing specimens on site), and these samples were subsequently transported back to the hospital for analysis.

Statistical analysis was performed with consultation from a statistician. Residents performed their own analysis by using the SPSS software program (SPSS Inc, Chicago, IL) and compared their results to those generated by the statistician. Group meetings in which the results of the data analysis were shared and explained to participating residents were held. A data safety and monitoring board comprised of several residents and 3 faculty members reviewed the laboratory data to determine which runners needed to be notified regarding abnormal laboratory results.

Manuscript Preparation and Publication
After data analysis was complete, manuscript preparation began. Each of the 3 primary manuscripts was written by the lead author and reviewed critically by all other authors. To date, 3 manuscripts have been generated for peer-reviewed journals. A published analysis reviewing risk factors for hyponatremia in marathon runners¹⁸ led to an invitation for the lead author to serve as a delegate to an international conference on exercise-associated hyponatremia.¹⁹ The lead authors for an analysis on troponin elevations in marathon runners were recognized as finalists for the Young Investigator's Award by the American College of Cardiology Annual Scientific Session.²⁰ An analysis of menstrual dysfunction and associated health problems in female marathon runners is currently undergoing review. A second year of subject enrollment and data collection was pursued during the 2003 Boston Marathon, with comparable rates of resident participation.

	DISCUSSION

TOP ABSTRACT THE PROJECT STUDY DESIGN DISCUSSION CONCLUSIONS REFERENCES

 
Here we describe a large prospective clinical research project successfully undertaken by residents while they were simultaneously pursuing a busy residency curriculum. By the end of the project, we felt we had successfully achieved each of our 3 primary goals.

Ours was not the first experience with a resident group research project. A previous report by the Internal Medicine Clinical Research Consortium Faculty describes a process in which collaboration among housestaff and faculty enabled successful research activity.²¹ However, more than a decade later, subsequent reports continue to demonstrate that lack of time, difficulty in finding a suitable topic, and unavailability of appropriate mentorship are common and important barriers for resident research activity.^1,4,11–17 We feel that a group resident research project is a relatively unexplored and potentially promising way to involve a large number of residents in a meaningful clinical research experience. We hope that our report will raise awareness of the potential strengths of this educational model.

Several factors were important to the success of this research model. We believe the most important factor was careful topic selection. That most of the planning, effort, and data collection centered around one 3-day weekend had several major advantages. First, the clarity and immovability of the study date served as a major motivating factor and prevented deadlines from slipping. Second, we found it relatively easy to generate and sustain enthusiasm for a relatively festive weekend of work together, a task that becomes substantially more difficult when data collection takes months or years. Third, resident work roles were remarkably diverse and flexible. Moreover, many of the tasks involved, such as phlebotomy and specimen handling, did not require acquisition of new skills. Other tasks such as obtaining informed consent required only a short period of training before race day. This allowed residents to tailor study involvement to their level of interest and availability, ranging from several hours to assist with drawing blood on race day to several months to assist with drafting the research protocol or analyzing the data.

We believe the second factor in accomplishing resident research using this model was the strong sense of collegiality within the program, making a collaborative research effort an appealing idea for the residents. We were surprised by the high level of enthusiasm and interest with which the residents embraced the study. We believe this reflected the tone of collaboration, cooperation, and resident ownership that was established from the beginning of the project. In addition, the residency program is one that is highly supportive of clinical research. At the time of the study, curricular changes were initiated to include more time for senior-level residents to participate in clinical research. The success of this project suggests that resident interest in clinical research is genuine and that residents will participate eagerly when the experience is tailored to fit into their residency experience.

The third factor to consider in this model was the strong faculty and institutional support. Although residents were responsible for each stage of the study, faculty mentorship was available and present throughout. Because the marathon study offered multiple study arms, faculty involvement crossed several disciplines including medicine, cardiology, emergency medicine, adolescent medicine, nephrology, laboratory medicine, and endocrinology. Faculty members expressed enthusiasm at the opportunity to provide mentorship to the residents, which was sustained throughout the study period.

More important was the counsel and guidance of a faculty member, in this case, a program director, directly participating in the steering committee. Similarly, we found strong institutional support from the General Clinical Research Center and the institutional review board. Both institutions were invested in the educational goals of the residents, exemplified by the supportive advice and critique they provided to a group of residents who were embarking on their first major clinical research protocol.

It is interesting to compare this approach to residency research to the more traditional model wherein individual residents work directly with a mentor. The traditional approach offers research topics that can be geared more to the individual's passion and interest; a collaborative approach affords a large number of residents the opportunity for participation in clinical research, many of whom would otherwise not have any exposure to clinical research at all. Inherent to large-group research is the risk of a diluted or fragmented experience or underrecognition, yet the opportunity for residents to collaborate offers some real-world preparation and experience with issues of academic professionalism that may promote success in future collaborative research efforts.

We acknowledge some limitations of our report that may affect the generalizability of our experience to other residency programs. First, the large size of our residency program was instrumental in meeting the staffing needs of our study, which raises the possibility that this model may not work as well in smaller training programs. However, important research questions exist that require fewer staff to answer. Our experience suggests that it is principally the feasibility of the research question along with the supportiveness of the work environment that are the critical prerequisites rather than the number of residents involved. Second, our perception of our projects' success as an educational endeavor is largely subjective, without corroborative quantitative data. We recognize that the quality of the learning experience may vary in different projects. In fact, the educational value of our project may have varied substantially among individual participants. Future efforts to quantify the educational outcomes of group resident clinical research activity would be of interest. Still, we hope that the qualitative description of the unique structure of our research project and our success in involving a large number of residents in the project will be of interest to medical educators looking for innovative ways to expose their trainees to clinical research. Third, group research is susceptible to discord over authorship, especially when those participating are at a similar level of training. However, we found that early and candid discussions delineating work roles and authorship assignment were invaluable and provided a natural forum in which to discuss teamwork and professionalism in the academic environment. In the end, it is important to note that residents accounted for 80% of the authors for the manuscripts developed, reflecting the primary role that residents played in conducting this study.

	CONCLUSIONS

TOP ABSTRACT THE PROJECT STUDY DESIGN DISCUSSION CONCLUSIONS REFERENCES

 
The Boston Marathon Study enabled a large number of residents to participate in clinical research during residency training. Careful topic selection and dedicated faculty mentorship are essential elements to a successful resident group research project. A diversity of roles and responsibilities, large and small, allows a large group of residents to become involved with varying levels of participation. Good communication is essential to ensure that major educational lessons from the project are shared with all residents involved. Finally, careful attention must be given to maintaining a positive, collaborative atmosphere and ensuring that all major efforts are recognized and rewarded appropriately.

	ACKNOWLEDGMENTS

 
This research was supported in part by National Institutes of Health grant RR-02172 and the Kobrun and Burnes Family Funds.

We acknowledge the residents of the 2002–2003 and 2003–2004 Boston Combined Residency Program (Children's Hospital Boston and Boston Medical Center) and the residents of the 2002–2003 and 2003–2004 Harvard Combined Medicine-Pediatrics Program for their dedication and commitment to the project. In addition, we acknowledge the considerable support and contribution from the nursing staff at Children's Hospital Boston and the faculty from the Departments of Medicine and Cardiology at Children's Hospital Boston.

	FOOTNOTES

 
Accepted Oct 26, 2005.

Address correspondence to Andrew Y. Shin, MD, Children's Hospital Boston, Department of Cardiology, Bader 2, 300 Longwood Ave, Boston, MA 02115. E-mail: andrew.shin{at}childrens.harvard.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

All listed authors participated and fulfilled roles in study design, data collection, and interpretation of the data for the clinical research project we describe in this work. In addition, the authors contributed to the intellectual content and reviewed and approved the final version of this report. Drs Shin and Almond contributed equally to this report. Dr Shin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

	REFERENCES

TOP ABSTRACT THE PROJECT STUDY DESIGN DISCUSSION CONCLUSIONS REFERENCES

 

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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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This Article Abstract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Shin, A. Y. Search for Related Content PubMed Articles by Shin, A. Y. Related Collections Office Practice Social Bookmarking                         What's this?