3.1. The Students’ Mission Lists and Research Topics
The students’ mission lists follow a template, mapping out their research topics in “basic research tasks,” “clinical research tasks,” “papers under review,” and “published papers.” Each topic, in the form of the title of a planned paper, is prospectively depicted as progressing on a course of idea, protocol, data collection, data analysis, and writing, with the targets of completion indicated by stages (around two months for one stage), such as “2012-Stage I data collection 40%” and “2012-Stage IV writing 20%”. The students are expected to keep to their timeline and volunteer to present on the progress of their on-going topics at the section’s monthly research meetings, for discussions and for comments from the section director. An idea and its protocol must be approved by the director before a student can go ahead with data collection. A new topic may be added to a student’s mission list as a result of research meeting discussions, and a topic deemed unfruitful may be deleted from one’s mission list. Those topics that are not completed (in the sense of publishing the target paper) before a student’s graduation will be passed on to other students or new students.
indicates the study program and year of study for each of the 14 interview participants (referred to as S1–S14) at the time of the present study, and shows their research profile in terms of the numbers of basic and clinical research topics, papers under review, and papers published (since they entered the department).
suggests that at the time of the study, the students had a total of 17 basic topics (Mean = 1.21), 71 clinical topics (Mean = 5.07), and a total of 7 and 4 papers published in Chinese and English respectively, in addition to a number of “under review” papers. Apparently, with the many topics listed in their mission lists, the students are encouraged to go beyond the publication requirement set by their universities, which usually consists of one article in an indexed Chinese journal for a Master’s student, or two articles in overseas English-medium SCI (Science Citation Index) journals (or one such article plus two Chinese papers) for a doctoral student. To manage their many topics, the students generally prioritize a topic for which there are ready data (e.g., utilizing their section’s database; see below) or for which data collection is relatively short-term, and aim to write up the paper before moving on to the next topic of focus.
3.1.1. Basic and Clinical Research Topics: Where They Come from
A student’s basic research topic is often part of a larger project of which the student’s second-tier supervisor is the principal investigator. In such cases, a listed topic may have been more or less designated by his supervisor when a student first entered the department. However, a basic research topic can also be proposed by a student’s second-tier supervisor or the section director in light of some clinical discovery (e.g., considering the possibility of genetic cause, from three members in a family having the same rarely-found orthopedic problem). Occasionally, a basic research task has been derived from a clinically-oriented topic listed under the name of a fellow student.
Most clinical topics have been suggested by the section director or the second-tier supervisors. If a topic is suggested by the section director, this can be at the section’s daily morning report sessions attended by doctors and students (case report topics in particular tend to be raised at this time when the director checks through patient records); or it may be during a monthly research meeting following some discussion, or at the end of such a meeting with the director handing out sheets of paper recorded with topics to a second-tier supervisor, or “bidding” for student volunteers to take on. According to the students, the ideas proposed by the director stem from his clinical experience and/or journal article reading, or from a recent attendance at an international conference overseas. When a topic is initiated by a second-tier supervisor, it can be at a supervisory meeting with his students, in light of his clinical experience and/or reading, or at the students’ Monday morning reading report session where the supervisors take turns to attend.
A small number of basic and clinical research topics have been initiated by the students themselves, often in consultation with a fellow student, on the basis of reading and with reference to the previous topics in their teams, and/or the data available. Yet another set of topics have been inherited from a previous student or passed over by a current fellow student (e.g., as a result of the latter’s adjustment of research focus).
3.1.2. Using Databases
The spine section has an ever-expanding database of digitalized clinical case records of the patients hospitalized in the section from the early 2000s. The database is organized by digital folders labeled after the patients’ names plus consecutive numbers. A particular patient-case folder typically includes a photo of a film parcel of the patient (which shows name, age, gender, diagnosis, etc.), and pre- and post-operative X-ray films, CT films, MRI films, and appearance photos. Searching through the database is made possible by the use of a data management platform. To access the data in the system, the students should first decide what they want through searching, and then submit an application to the section director. Following approval, the section secretary will download the relevant folders to a desktop computer located in a classroom at the section for the students to access and conduct measurements and statistical analyses accordingly.
The students can gain access to those radiographic films that have not yet been gathered into the section’s database (by the section secretary) as well as old films missing in the database with authorization through the Radiography Work Station, which is a computerized system hosted by the Radiology Department of the hospital that automatically stores all films shot at the hospital. Other than making use of the section’s database and the Radiology Department’s storage of films, the students collect much of the clinical data they need in person, primarily at the OPC, as shown below.
The spine section also has a databank of blood samples, which is used for laboratory-based research. As discussed below, the students play a major role in building this databank through their accumulation of blood samples at the OPC.
3.1.3. Collecting Data for Research
Against a backdrop of increasing emphasis on ethical research in medicine in China [10
], the hospital has a Committee on Medical Ethics that is in charge of the ethical clearance of the research projects proposed by its staff. The students, overseen by the section director and their second-tier supervisors, are expected to observe ethical mandates in their data collection activities. The general practice among the students is to explain the research purpose of the data collection to the patients and obtain informed consent orally whenever necessary.
a. Collecting basic research data on the wards
On the wards, a student obtains a patient’s blood sample from a nurse, who conducts exsanguination with the patient for routine check in the morning, and a student obtains a bit of a patient’s tissue sample at the operation room, with the help of a doctor performing the operation and a nurse on duty. In both cases, communication beforehand with the medical staff and the patients concerned is needed. At the OPC, as noted below, blood samples from patients are taken in a “back-stage” room (as the students call it).
b. Collecting clinical and basic research data at the OPC
All 14 students work as assistants to the section director at the OPC, for two half-days a week. The number of patients they receive on each half-day can vary from 70 to over 100 (the latter during primary/secondary school students’ summer holidays). The section director circulates between several diagnosis rooms to see patients, while the students distribute themselves in different locations—the front-desk, diagnosis rooms, and a “back-stage” room—and combine their assistant jobs with data collection in teamwork.
Two students stationed at the front-desk make sure the incoming registered patients have all the needed films ready before they are allowed in. As they conduct this screening, if they come across a case that matches a research topic of a fellow student, they would quickly note down on a sheet of paper the name of the patient with a brief label of the issue concerned (e.g., “brace”), together with the name of the fellow student. They would deliver the sheets of paper during breaks to the diagnosis rooms inside for the fellow student’s attention. As the students have frequent opportunities to hear each other’s work (in particular at monthly research meetings of the section), they know each other’s topics well and are therefore able to pass on information. Such teamwork is in fact strongly encouraged by the section director and their second-tier supervisors.
Two or three students work in each diagnosis room: they elicit a patient’s report of his/her problems and write the patient record to pave the way for the section director’s visit to the patient when it is the latter’s turn. They may also scribe the director’s diagnosis and instructions into the patient record and help to re-state and clarify points to the patient when the director has moved on to the next patient. In the process, as they come across a patient whose case falls under his own or a fellow student’s topic, he would pencil “To [his own/a fellow student’s name]” on the front side of the film parcel of the patient; a student responsible for using a digital camera to photograph the patients’ films (against a negatoscope) together with the front side of the film parcel would then be able to send the photographs afterwards to the relevant fellow students.
Finally, another two students work in a “back-stage” room, where they perform such procedures as measuring and recording the weight, height, and arm span for patients as necessary, conducting blood extraction (usually on a patient’s first visit) after explaining the relevant research purpose to the patients and obtaining their consent orally, and helping patients to fill out a questionnaire which evaluates their quality of life. The measurements and the questionnaire information serve both as an important part of the patients’ clinical records in longitudinal monitoring and as potentially valuable research data. The blood samples collected are added to the section’s databank of blood samples for laboratory-based research.
The complete set of relevant information and films for a patient who passes from the OPC to the wards where he/she undergoes a surgery will be gathered by the clinical front-line second-tier supervisors for the section secretary to input into the section’s database. The case data of those patients who come to the OPC for regular checks or post-operative follow-up checks are collected by the students, as described above. The radiographic data amassed by the students in effect form their “personal databases” (likewise organized by folders for individual patients), which they use for their clinical research topics. Before leaving the department at graduation, the students will, as required, copy all the radiographic data they have gleaned over time on a CD-ROM to submit to the department and delete any backups from their files.