- Email: [email protected]
The Maastricht–Duke bridge: An era of mentoring in clinical research – A model for mentoring in clinical research - A tribute to Dr. Galen Wagner
Available online at www.sciencedirect.com
ScienceDirect Journal of Electrocardiology 50 (2017) 16 – 20 www.jecgonline.com
The Maastricht–Duke bridge: An era of mentoring in clinical research – A model for mentoring in clinical research - A tribute to Dr. Galen Wagner Loek Meijs, MD, a, b Robbert Zusterzeel, MD, PhD, c, d,⁎ Hein JJ Wellens, MD, PhD, e Anton PM Gorgels, MD, PhD e a
Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands c United States Food and Drug Administration, Silver Spring, MD, USA d Harvard TH Chan School of Public Health, Boston, MA, USA Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands b
e
Abstract
Objective: With the passing of Dr. Galen Wagner, an exceptional collaboration between Maastricht University Medical Center, The Netherlands, and Duke Clinical Research Institute, USA, has come to an end. This article focuses on the background of what Galen coined the Maastricht–Duke bridge (MD-bridge), its merits, limitations and development throughout the years, and his special role. Methods: Between 2004 and 2015, 23 Maastricht University medical students and post-graduate students were enrolled in the 4-month research elective, mentored by Galen and the Maastricht co-mentor. They were asked to complete a survey about their MD-bridge experience. Results: Sixteen out of the 23 students responded. None but 1 participant had prior research experience. Following their MD bridge-program most participants published 1 or more manuscripts and/or presented their research in an international setting. They felt they had full responsibility as a leader of their project with all participants developing meaningful skills useful in their current job. Fourteen out of 16 would recommend the MD-bridge experience to others. Participants considered the program of great value for their personal growth and independence, giving a feeling of achievement. In addition, for some participants it led to careers in foreign countries including medical practice and research, or obtaining PhDs. Conclusions: With Galen's impressive career of mentoring students, including the 23 MD-bridge participants, he has left behind an amazing concept of self-development in research and personal life. The successes of the MD-bridge prove that it is possible for students to be young investigators during or just after medical school with the potential to contribute to developing meaningful skills and noteworthy careers. Collaborations between international universities, such as the MD-bridge, are feasible and should be embraced by other institutions. Published by Elsevier Inc.
Keywords:
Research; Mentoring; International; Collaboration; Electrocardiography; University
Introduction With the passing of Dr. Galen Wagner, an exceptional collaboration between Maastricht University Medical Center (MUMC) [1], The Netherlands, and Duke University Clinical Research Institute (DCRI) [2], Durham, North Carolina, USA has come to an end. This report focuses on the background of what Galen coined the Maastricht–Duke bridge (MD-bridge), its merits, limitations and development throughout the years. To achieve this, responses from the majority of participants in ⁎ Corresponding author at: 10903 New Hampshire Ave 64-2014, Silver Spring, MD 20993, USA. E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.jelectrocard.2016.10.009 0022-0736/Published by Elsevier Inc.
this program over the last 10 years have been collected and structured as well as input from Maastricht University medical school. The MD-bridge would never have existed without the continuous input and efforts of the late Galen Wagner. Therefore, this article commences with an overview of the philosophy behind the program (the university without walls), as offered by Galen. University without walls Thinking and acting beyond borders, both literally and figuratively, has always been a major aspect of Galen's concept of clinical research. His primary interest was electrocardiology but with the advent of new imaging techniques, he recognized
L. Meijs et al. / Journal of Electrocardiology 50 (2017) 16–20
new opportunities to improve the ECG as a diagnostic tool by using information from multimodal imaging techniques such as the coronary angiogram, the echocardiogram and MRI. Galen has always collaborated with likeminded researchers who were open to work together. Much effort was spent not only to build solid collaborations, but also establishing a background to train students to do research in a transnational environment. Thus, for clinical, research and research-education purposes, walls between universities were broken down and bridges were built to establish bilateral collaborations and exchange programs. This is what Galen called the “university without walls”. The story of the MD-bridge started in 2003 with the collaboration between one of the authors (Anton Gorgels), mentor at the MUMC and Dr. Mitch Krukoff, at DCRI, consisting of a study program on the analysis of post-reperfusion arrhythmias. Students were encouraged to go abroad (from their home institution in Maastricht to DCRI in Durham [NC]) and spend dedicated research time at Mitch's laboratory. Subsequently, the program was continued by PhD fellows, but Galen wanted to continue research electives at the student level. A specific need for a training program to teach students how to do their own research using databases for which they had to build their own scientific collaborations emerged. Having been trained by Galen himself, Mitch found in Galen an excellent potential mentor for students to be coached in designing and performing their authentic scientific projects. Soon Galen was put in contact with Anton and the idea of an extended exchange program in the line of the aforementioned collaboration between Mitch and Anton took shape.
Methods This article discusses the evaluation of the MD-bridge, a research elective program of Maastricht medical students supervised by a combined mentorship from Duke and Maastricht. Between 2004 and 2015, 23 Maastricht University medical students and post-graduate students were enrolled in the program and were asked to complete a survey with questions about their MD-bridge experience. The mission was to develop young investigators being capable of performing clinical research independently. Within the time frame of 4 months students were challenged to have a complete research experience from hypothesis to peer-reviewed journal manuscript submission and presentation of their work in an international context. The student was appointed as the principal investigator being responsible for all steps in the research project such as hypothesis generation, finding a suitable database, the description of the study project, bringing together the necessary co-investigators, the collection of data, data analysis using appropriate statistics, reaching the correct conclusions, and writing the manuscript ready for the reviewing process. Following the “university without walls” concept described earlier, co-investigators, databases and other aspects of the research process could be invited from other institutions. In practice, after a preparation phase in Maastricht with an initial description of the study hypothesis and required database, students went in pairs to Duke University for about 18 weeks, usually in their last year of
17
medical school. An Outcomes Research Practicum [3], developed at Duke, was utilized during the Maastricht-based preparation phase to provide a 4-point workshop outline format for research study design: Introduction, General Methods, Statistical Methods, and Logistics. In detail, the initiation of the research mentorship was divided in 4 phases: • Phase 1 consisted of the recruitment of an individual by the mentor at Maastricht University. The local mentor had to weigh and decide if a person was capable of completing a challenging research project. • In phase 2, a study design was created according to the Outcomes Research Practicum template with input from Galen, the local mentor, the student and from other potential collaborators at Duke, Maastricht or elsewhere. A potential research database was selected that was either from Maastricht University, Duke University or from one of the collaborative authors' institutions. This preparation at the local university was of key importance for the whole mentorship and had to be completed before a student went on-site to start the research project. • Phase 3 was to actually leave the home institution and start the process of data acquisition, analysis, and writing the manuscript. Ideally, the student would finish the manuscript and submit it to a peer-reviewed journal before returning home. In this phase the student was mentored by Galen in person and the mentor at the home institution via phone or video conferencing but was personally responsible for study progression and communication with collaborators. • Phase 4 consisted of completing the manuscript and submitting it for publication. The student would also go through the process of responding to reviewers' comments and resubmission of the manuscript until it was published. If possible, the student would also present his/her work in an international context.
Results In total 16 out of 23 students that attended the MD-bridge program responded to the survey about their experience. The output of the various scientific projects resulted in many publications in scientific journals as well as presentations (oral and in poster-format) at various small or larger international research conferences. This results section summarizes, as completely as possible, to what extent the program has led to output in terms of publications of the research projects, and also focuses on personal achievements of all attendees during their dedicated time at Duke University and the years thereafter. Program output Table 1 summarizes the MD-bridge output from the 16 individual participants that completed the survey. What should be emphasized in discussing the output of this program is that apart from one, none of the participants had prior research experience before starting the program, but most of them published 1 or more manuscripts and presented their research
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L. Meijs et al. / Journal of Electrocardiology 50 (2017) 16–20
Table 1 Answers from the 16 individual respondents that participated in the MD-Bridge program. Research before Leadership Publications as Presentations as Development Helpful to be in Research after MD-bridge skills Year MD-bridge of project part of MD-bridgea part of MD-bridge of new skills different setting MD-bridge useful in current job 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
2004 2004 2006 2006 2007 2007 2008 2009 2009 2010 2011 2011 2011 2012 2014 2014 a
Yes No No No No No No No No No No No No No No No
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
– – 1 4 1 2 2 6 6 1 1 1 3 1 1 1
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A N/A Yes N/A Yes Yes
No Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No No
No Yes Yes No No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No
Publications are either as first-author or co-author and some participants worked together on multiple publications.
in an international setting. In addition, all but 1 participant felt that they had full responsibility as a leader of their project. All participants developed meaningful skills, in the majority of cases, useful in their current job. Fourteen out of the 16 would recommend the MD-bridge experience to others. The research databases that were used during the MD-bridge program were manifold and can be divided into 3 separate parts: 1) experimental - using databases from international randomized clinical trials, 2) test - using databases from university without walls collaborators (Johns Hopkins University [Maryland, USA], Glasgow University [Ireland], and Lund University [Sweden]), and 3) continued - using a wide variety of retrospectively and prospectively acquired databases from Maastricht and/or Duke. These databases were used to study different topics including: 1) myocardial infarction, ischemia and scar [4–23], and 2) ventricular arrhythmias, conduction disorders and dyssynchrony [22,24,25]. These topics were covered in 22 peer-reviewed manuscripts in 7 scientific journals. Magnetic and eLectronic technologies meeting One of the international scientific conferences that should be highlighted, as one of the major features of the MD-bridge program, is the Magnetic And eLectronic Technologies (MALT) meeting [26,27]. Originally founded in Scotland (another reason why the acronym “MALT” was more than suitable), this yearly 2-day conference, organized by an international study group consisting of biomedical engineers, clinical and basic science cardiologists and physiologists, is held in different parts of Europe and is an excellent platform for young investigators to present their work. It was utilized for experience in international presentations of both planned and completed research projects of the young investigators and included a young investigators competition. It was also the perfect opportunity for students and supervisors of different universities to meet and interact, often evolving in further scientific collaborations, which was, as mentioned earlier, one of the specific implications of Galen's legacy.
The advantage of meetings with a maximum of 30 participants was that there was not only more time for presenting but also, perhaps even more important, for discussion which is not always possible at large scientific conferences. By presenting and interpreting their own research, students were challenged to convey their knowledge to an audience which could immediately respond; challenging but certainly not intimidating because of the smaller number of participants. The opinion of the Maastricht University medical school We asked Maastricht University, who record the experiences of students for all research electives offered by the university, about their opinion of the MD-bridge program. The MD-bridge program received exceptional positive feedback and recognition of their great value compared to other programs expressing their opinion over the whole period of the program. To express their gratitude for Galen's crucial role in the MD-Bridge program Maastricht University gave him the Maastricht International Mentorship Award, in recognition for his constant efforts to involve Maastricht medical students in research. Personal experiences The focus of the MD-bridge program went beyond scientific output. Just as important was the personal experience and personal development of the participants. Table 1 shows that for almost all participants it was very stimulating to be in a different environment than the home institution. Participants felt that it significantly contributed to their personal growth, independence and feeling of achievement. In addition, for some participants it led to careers in foreign countries in medical practice or further research, like obtaining a PhD. To complete the MD-bridge experience, Galen, as the editor-in-chief of the Journal of Electrocardiology, encouraged participants to also act as peer-reviewers for the journal. Potential improvements We asked participants about potential improvements to the MD-bridge program and the inherent challenges of an
L. Meijs et al. / Journal of Electrocardiology 50 (2017) 16–20
international collaborative research program for students. To have only one main mentor at each institution can be challenging if the interaction between the student and the mentor for effective interaction and productivity is not optimal. In most cases these issues were resolved by finding a different mentor for the student allowing the student to continue his/her research project. Other challenges were that it was not always possible for 2 or more students to go together and support each other during the experience abroad. Also more preparation before starting the project abroad was considered useful mainly in the earlier years of medical school. This is not necessarily a challenge of the program itself but maybe more of their stage of medical education in general. Overall, participants felt that the program should be expanded to include other institutions as well.
Discussion This article gives an overview of an exceptional mentoring program exclusively designed to introduce students into the concept and performance of their own authentic research. A large majority of students that attended the MD-bridge have rated their experience as highly positive in terms of educational merit, scientific output and contribution to their personal and professional development. Since the primary goal of this program consisted of the student's achievements, this MD-bridge can be termed a successful program. Throughout his research career, Galen noticed that education at universities was mainly focused on training students to be good doctors instead of also becoming good researchers (something he called “studentosis”). Medical schools were (and for the majority still are) interested in teaching students information, and not teaching students how to perform research. This was in conflict with Galen's perspective of the value of clinical research in the students' medical curriculum. It is important to emphasize Galen's ideas about mentoring. Often research projects have already started, and participating students fulfill the mentors' requests. This is a way of “passive” participation. In Galen's opinion, the focus had to be on coaching and mentoring the student to design their own research project and go through the whole scientific process from idea to study design, hypothesis generation, data acquisition, data analysis and eventually leading to the development of a scientific manuscript that could be submitted to a journal for peer-review and publication. Much emphasis was put on the concept of students taking leadership of a research project. Galen often used the metaphor of a bus driver (representing the student) who is the one to decide which passengers (representing the co-authors) are allowed on the bus (representing the research project) and has the leadership in steering the bus to its final destination (representing publication of a manuscript). Furthermore, it was key that the research-pupils had to provide themselves with research resources, irrespective of what kind of resources these would be (i.e. prospectively collecting data or connecting with other researchers to be able to use existing data). Galen, using his broad scientific network, facilitated this process; however, it was for the student to decide who could finally be included as a co-author. In addition, the concept of data sharing fit well
19
within Galen's view doing research. This so-called “tradebarter-system” could be, in his opinion, a solution for the often rigid and polarized attitude which is common in the scientific world and nowadays seems more present than ever before. By collaboration and sharing of data, research outcome (and thus patient care) could be dramatically improved in terms of efficiency, time and cost effectiveness. Thus, in summary, true mentoring means focusing on the individual and helping them to develop themselves. Another very important aspect of the MD-bridge was that students had to travel to Durham in order to optimally benefit from the interactions with Galen. This meant that students had to leave their safe, familiar home environment and were left to themselves to a great extent, asking for investment in self-development eventually resulting in independence and autonomy. Since these characteristics are key elements of the research philosophy of Galen, students were challenged in a double sense to work on their independence and leadership, both in research as well as their personal lives. Needless to say, this demanded a lot of courage from the students in the first place. Practically, Galen, along with his ECG-Core Laboratory secretary Mrs. Kathy Shuping even facilitated the research time by supplying addresses for housing and contacts with the International Student Office of Duke University in order to settle all formalities involved with visiting the United States as a student. Despite the fact that the majority of participants submitted a positive rating of the MD-bridge program, there were some cases in which the program did not succeed for various reasons. In case of a troubled interaction between student and mentor or stagnation of study progress due to data problems or collaboration errors, all efforts were spent to search for alternatives to eventually fulfill the primary goal of the program. Examples of these alternatives are transition to another local or at home mentor or switching to other research sources. Conclusions and future perspectives With Galen's impressive career of mentoring students, including the 23 MD-bridge program participants, he has left behind an amazing concept of self-development in research and personal life. The successes of the MD-bridge prove that it is possible for students to be young investigators during or just after medical school and that it has the potential to contribute to developing meaningful skills and noteworthy careers. Collaborations between international universities, such as the MD-bridge, are feasible and should be embraced by other institutions. References [1] Maastricht University. Faculty of health, medicine and life sciences. at https://www.maastrichtuniversity.nl/about-um/faculties/facultyhealth-medicine-and-life-sciences. [2] Duke Clinical Research Institute. athttps://www.dcri.org/. [3] Davis III TH, Wagner GS, Gleim G, Andolsek KM, Arheden H, Austin R, et al. Problem-based learning of research skills. J Electrocardiol 2006;39:120–8. [4] Majidi M, Kosinski AS, Al-Khatib SM, Lemmert ME, Smolders L, van Weert A, et al. Reperfusion ventricular arrhythmia 'bursts' in TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction: a more precise definition of reperfusion arrhythmias. Europace 2008;10:988–97.
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[5] Smolders L, Majidi M, Krucoff MW, Crijns HJ, Wellens HJ, Gorgels AP. Preexcitation and myocardial infarction: conditions with confusing electrocardiographic manifestations. J Electrocardiol 2008;41:679–82. [6] Geerse DA, Wu KC, Gorgels AP, Zimmet J, Wagner GS, Miller JM. Comparison between contrast-enhanced magnetic resonance imaging and Selvester QRS scoring system in estimating changes in infarct size between the acute and chronic phases of myocardial infarction. Ann Noninvasive Electrocardiol 2009;14:360–5. [7] Majidi M, Kosinski AS, Al-Khatib SM, Lemmert ME, Smolders L, van Weert A, et al. Reperfusion ventricular arrhythmia 'bursts' predict larger infarct size despite TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction. Eur Heart J 2009;30:757–64. [8] Rovers WC, van Boreen MC, Robinson M, Martin TN, Maynard C, Wagner GS, et al. Comparison of the correlation of the Selvester QRS scoring system with cardiac contrast-enhanced magnetic resonance imaging-measured acute myocardial infarct size in patients with and without thrombolytic therapy. J Electrocardiol 2009;42:139–44. [9] Ubachs JF, Engblom H, Hedstrom E, Selvester RH, Knippenberg SA, Wagner GS, et al. Location of myocardium at risk in patients with firsttime ST-elevation infarction: comparison among single photon emission computed tomography, magnetic resonance imaging, and electrocardiography. J Electrocardiol 2009;42:198–203. [10] Knippenberg SA, Wagner GS, Ubachs JF, Gorgels A, Hedstrom E, Arheden H, et al. Consideration of the impact of reperfusion therapy on the quantitative relationship between the Selvester QRS score and infarct size by cardiac MRI. Ann Noninvasive Electrocardiol 2010;15:238–44. [11] Bouwmeester S, van Hellemond IE, Maynard C, Bekkers SCAM, van der Weg K, Wagner GS, et al. The relationship between initial STsegment deviation and final QRS complex changes related to the posterolateral wall in acute inferior myocardial infarction. J Electrocardiol 2011;44:509–15. [12] Bouwmeester S, van Hellemond IE, Maynard C, Young D, Bethea C, Gorgels A, et al. The stability of the ST segment estimation of myocardial area at risk between the prehospital and hospital electrocardiograms in patients with ST elevation myocardial infarction. J Electrocardiol 2011;44:363–9. [13] Meijs LP, Gorgels AP, Bekkers SC, Maynard CC, Lemmert ME, Wagner GS. The relationship between serial postinfarction T wave changes and infarct size and ventricular function as determined by cardiac magnetic resonance imaging. J Electrocardiol 2011;44:555–60. [14] van Hellemond IE, Bouwmeester S, Olson CW, Botker HE, Kaltoft AK, Nielsen SS, et al. Consideration of QRS complex in addition to STsegment abnormalities in the estimated "risk region" during acute anterior myocardial infarction. J Electrocardiol 2011;44:370–6. [15] Weinsaft JW, Kim HW, Crowley AL, Klem I, Shenoy C, van Assche L, et al. LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR. JACC Cardiovasc Imaging 2011;4:702–12.
[16] Hassell ME, Bekkers SC, Loring Z, van Hellemond I, Bouwmeester S, van der Weg K, et al. The predictive value of an ECG-estimated acute ischemia index for prognosis of myocardial salvage and infarct healing 3 months following inferior ST-elevated myocardial infarction. J Electrocardiol 2013;46:221–8. [17] Korver FW, Hassell M, Smulders MW, Bekkers SC, Gorgels AP. Correlating both Aldrich and Hellemond score with cardiac magnetic resonance imaging endocardial surface area calculations in the estimation of the area at risk. Electrocardiography scores and endocardial surface area calculations: do they correlate? J Electrocardiol 2013;46:229–34. [18] Ruth RA, Wagner GS, Soliman Hamad M, Serroyen J, Gorgels AP. Ischemia index to predict post coronary artery bypass graft change in left ventricular ejection fraction. J Electrocardiol 2013;46:235–9. [19] van Hellemond IE, Bouwmeester S, Olson CW, Hassell M, Botker HE, Kaltoft AK, et al. Consideration of QRS complex in addition to ST segment abnormalities in the estimation of the 'risk region' during acute inferior myocardial infarction. J Electrocardiol 2013;46:215–20. [20] Meijs LP, Galeotti L, Pueyo EP, Romero D, Jennings RB, Ringborn M, et al. An electrocardiographic sign of ischemic preconditioning. Physiol Heart Circ Physiol 2014;307:H80–7. [21] Vervaat FE, Bouwmeester S, van Hellemond IE, Wagner GS, Gorgels AP. Consideration of QRS complex in addition to ST-segment abnormalities in the estimation of the "risk region" during acute anterior or inferior myocardial infarction. J Electrocardiol 2014;47:535–9. [22] Hannink LG, Wagner GS, Kisslo J, Alenezi FA, Shaw LK, Hofmann P, et al. Influence of QRS infarct score and QRS duration prior to transcatheter aortic valve replacement on follow-up left ventricular end systolic volume in patients with new persistent left bundle branch block. J Electrocardiol 2015;48:637–42. [23] Majidi M, Kosinski AS, Al-Khatib SM, Smolders L, Cristea E, Lansky AJ, et al. Implications of ventricular arrhythmia "bursts" with normal epicardial flow, myocardial blush, and ST-segment recovery in anterior ST-elevation myocardial infarction reperfusion: a biosignature of direct myocellular injury "downstream of downstream". Acute Cardiovasc Care 2015;4:51–9. [24] Zusterzeel R, Ter Bekke RM, Volders PG, Leijten FM, van den Wijngaard A, Serroyen J, et al. Right-ventricular enlargement in arrhythmogenic right-ventricular cardiomyopathy is associated with decreased QRS amplitudes and T-wave negativity. Ann Noninvasive Electrocardiol 2013;18:555–63. [25] Leeters IP, Davis A, Zusterzeel R, Atwater B, Risum N, Sogaard P, et al. Left ventricular regional contraction abnormalities by echocardiographic speckle tracking in combined right bundle branch with left anterior fascicular block compared to left bundle branch block. J Electrocardiol 2016;49:353–61. [26] Magnetic and eLectronic technologies meeting. at http://malt-meeting.net. [27] Pahlm O, Swenne CA, Ugander M, Warren SG, Wagner GS. Scientific STAFF and MALT meetings - past, present, and future. J Electrocardiol 2016;49:259–62.
ScienceDirect Journal of Electrocardiology 50 (2017) 16 – 20 www.jecgonline.com
The Maastricht–Duke bridge: An era of mentoring in clinical research – A model for mentoring in clinical research - A tribute to Dr. Galen Wagner Loek Meijs, MD, a, b Robbert Zusterzeel, MD, PhD, c, d,⁎ Hein JJ Wellens, MD, PhD, e Anton PM Gorgels, MD, PhD e a
Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands c United States Food and Drug Administration, Silver Spring, MD, USA d Harvard TH Chan School of Public Health, Boston, MA, USA Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands b
e
Abstract
Objective: With the passing of Dr. Galen Wagner, an exceptional collaboration between Maastricht University Medical Center, The Netherlands, and Duke Clinical Research Institute, USA, has come to an end. This article focuses on the background of what Galen coined the Maastricht–Duke bridge (MD-bridge), its merits, limitations and development throughout the years, and his special role. Methods: Between 2004 and 2015, 23 Maastricht University medical students and post-graduate students were enrolled in the 4-month research elective, mentored by Galen and the Maastricht co-mentor. They were asked to complete a survey about their MD-bridge experience. Results: Sixteen out of the 23 students responded. None but 1 participant had prior research experience. Following their MD bridge-program most participants published 1 or more manuscripts and/or presented their research in an international setting. They felt they had full responsibility as a leader of their project with all participants developing meaningful skills useful in their current job. Fourteen out of 16 would recommend the MD-bridge experience to others. Participants considered the program of great value for their personal growth and independence, giving a feeling of achievement. In addition, for some participants it led to careers in foreign countries including medical practice and research, or obtaining PhDs. Conclusions: With Galen's impressive career of mentoring students, including the 23 MD-bridge participants, he has left behind an amazing concept of self-development in research and personal life. The successes of the MD-bridge prove that it is possible for students to be young investigators during or just after medical school with the potential to contribute to developing meaningful skills and noteworthy careers. Collaborations between international universities, such as the MD-bridge, are feasible and should be embraced by other institutions. Published by Elsevier Inc.
Keywords:
Research; Mentoring; International; Collaboration; Electrocardiography; University
Introduction With the passing of Dr. Galen Wagner, an exceptional collaboration between Maastricht University Medical Center (MUMC) [1], The Netherlands, and Duke University Clinical Research Institute (DCRI) [2], Durham, North Carolina, USA has come to an end. This report focuses on the background of what Galen coined the Maastricht–Duke bridge (MD-bridge), its merits, limitations and development throughout the years. To achieve this, responses from the majority of participants in ⁎ Corresponding author at: 10903 New Hampshire Ave 64-2014, Silver Spring, MD 20993, USA. E-mail addresses: [email protected], [email protected] http://dx.doi.org/10.1016/j.jelectrocard.2016.10.009 0022-0736/Published by Elsevier Inc.
this program over the last 10 years have been collected and structured as well as input from Maastricht University medical school. The MD-bridge would never have existed without the continuous input and efforts of the late Galen Wagner. Therefore, this article commences with an overview of the philosophy behind the program (the university without walls), as offered by Galen. University without walls Thinking and acting beyond borders, both literally and figuratively, has always been a major aspect of Galen's concept of clinical research. His primary interest was electrocardiology but with the advent of new imaging techniques, he recognized
L. Meijs et al. / Journal of Electrocardiology 50 (2017) 16–20
new opportunities to improve the ECG as a diagnostic tool by using information from multimodal imaging techniques such as the coronary angiogram, the echocardiogram and MRI. Galen has always collaborated with likeminded researchers who were open to work together. Much effort was spent not only to build solid collaborations, but also establishing a background to train students to do research in a transnational environment. Thus, for clinical, research and research-education purposes, walls between universities were broken down and bridges were built to establish bilateral collaborations and exchange programs. This is what Galen called the “university without walls”. The story of the MD-bridge started in 2003 with the collaboration between one of the authors (Anton Gorgels), mentor at the MUMC and Dr. Mitch Krukoff, at DCRI, consisting of a study program on the analysis of post-reperfusion arrhythmias. Students were encouraged to go abroad (from their home institution in Maastricht to DCRI in Durham [NC]) and spend dedicated research time at Mitch's laboratory. Subsequently, the program was continued by PhD fellows, but Galen wanted to continue research electives at the student level. A specific need for a training program to teach students how to do their own research using databases for which they had to build their own scientific collaborations emerged. Having been trained by Galen himself, Mitch found in Galen an excellent potential mentor for students to be coached in designing and performing their authentic scientific projects. Soon Galen was put in contact with Anton and the idea of an extended exchange program in the line of the aforementioned collaboration between Mitch and Anton took shape.
Methods This article discusses the evaluation of the MD-bridge, a research elective program of Maastricht medical students supervised by a combined mentorship from Duke and Maastricht. Between 2004 and 2015, 23 Maastricht University medical students and post-graduate students were enrolled in the program and were asked to complete a survey with questions about their MD-bridge experience. The mission was to develop young investigators being capable of performing clinical research independently. Within the time frame of 4 months students were challenged to have a complete research experience from hypothesis to peer-reviewed journal manuscript submission and presentation of their work in an international context. The student was appointed as the principal investigator being responsible for all steps in the research project such as hypothesis generation, finding a suitable database, the description of the study project, bringing together the necessary co-investigators, the collection of data, data analysis using appropriate statistics, reaching the correct conclusions, and writing the manuscript ready for the reviewing process. Following the “university without walls” concept described earlier, co-investigators, databases and other aspects of the research process could be invited from other institutions. In practice, after a preparation phase in Maastricht with an initial description of the study hypothesis and required database, students went in pairs to Duke University for about 18 weeks, usually in their last year of
17
medical school. An Outcomes Research Practicum [3], developed at Duke, was utilized during the Maastricht-based preparation phase to provide a 4-point workshop outline format for research study design: Introduction, General Methods, Statistical Methods, and Logistics. In detail, the initiation of the research mentorship was divided in 4 phases: • Phase 1 consisted of the recruitment of an individual by the mentor at Maastricht University. The local mentor had to weigh and decide if a person was capable of completing a challenging research project. • In phase 2, a study design was created according to the Outcomes Research Practicum template with input from Galen, the local mentor, the student and from other potential collaborators at Duke, Maastricht or elsewhere. A potential research database was selected that was either from Maastricht University, Duke University or from one of the collaborative authors' institutions. This preparation at the local university was of key importance for the whole mentorship and had to be completed before a student went on-site to start the research project. • Phase 3 was to actually leave the home institution and start the process of data acquisition, analysis, and writing the manuscript. Ideally, the student would finish the manuscript and submit it to a peer-reviewed journal before returning home. In this phase the student was mentored by Galen in person and the mentor at the home institution via phone or video conferencing but was personally responsible for study progression and communication with collaborators. • Phase 4 consisted of completing the manuscript and submitting it for publication. The student would also go through the process of responding to reviewers' comments and resubmission of the manuscript until it was published. If possible, the student would also present his/her work in an international context.
Results In total 16 out of 23 students that attended the MD-bridge program responded to the survey about their experience. The output of the various scientific projects resulted in many publications in scientific journals as well as presentations (oral and in poster-format) at various small or larger international research conferences. This results section summarizes, as completely as possible, to what extent the program has led to output in terms of publications of the research projects, and also focuses on personal achievements of all attendees during their dedicated time at Duke University and the years thereafter. Program output Table 1 summarizes the MD-bridge output from the 16 individual participants that completed the survey. What should be emphasized in discussing the output of this program is that apart from one, none of the participants had prior research experience before starting the program, but most of them published 1 or more manuscripts and presented their research
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Table 1 Answers from the 16 individual respondents that participated in the MD-Bridge program. Research before Leadership Publications as Presentations as Development Helpful to be in Research after MD-bridge skills Year MD-bridge of project part of MD-bridgea part of MD-bridge of new skills different setting MD-bridge useful in current job 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
2004 2004 2006 2006 2007 2007 2008 2009 2009 2010 2011 2011 2011 2012 2014 2014 a
Yes No No No No No No No No No No No No No No No
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
– – 1 4 1 2 2 6 6 1 1 1 3 1 1 1
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A N/A Yes N/A Yes Yes
No Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No No
No Yes Yes No No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No
Publications are either as first-author or co-author and some participants worked together on multiple publications.
in an international setting. In addition, all but 1 participant felt that they had full responsibility as a leader of their project. All participants developed meaningful skills, in the majority of cases, useful in their current job. Fourteen out of the 16 would recommend the MD-bridge experience to others. The research databases that were used during the MD-bridge program were manifold and can be divided into 3 separate parts: 1) experimental - using databases from international randomized clinical trials, 2) test - using databases from university without walls collaborators (Johns Hopkins University [Maryland, USA], Glasgow University [Ireland], and Lund University [Sweden]), and 3) continued - using a wide variety of retrospectively and prospectively acquired databases from Maastricht and/or Duke. These databases were used to study different topics including: 1) myocardial infarction, ischemia and scar [4–23], and 2) ventricular arrhythmias, conduction disorders and dyssynchrony [22,24,25]. These topics were covered in 22 peer-reviewed manuscripts in 7 scientific journals. Magnetic and eLectronic technologies meeting One of the international scientific conferences that should be highlighted, as one of the major features of the MD-bridge program, is the Magnetic And eLectronic Technologies (MALT) meeting [26,27]. Originally founded in Scotland (another reason why the acronym “MALT” was more than suitable), this yearly 2-day conference, organized by an international study group consisting of biomedical engineers, clinical and basic science cardiologists and physiologists, is held in different parts of Europe and is an excellent platform for young investigators to present their work. It was utilized for experience in international presentations of both planned and completed research projects of the young investigators and included a young investigators competition. It was also the perfect opportunity for students and supervisors of different universities to meet and interact, often evolving in further scientific collaborations, which was, as mentioned earlier, one of the specific implications of Galen's legacy.
The advantage of meetings with a maximum of 30 participants was that there was not only more time for presenting but also, perhaps even more important, for discussion which is not always possible at large scientific conferences. By presenting and interpreting their own research, students were challenged to convey their knowledge to an audience which could immediately respond; challenging but certainly not intimidating because of the smaller number of participants. The opinion of the Maastricht University medical school We asked Maastricht University, who record the experiences of students for all research electives offered by the university, about their opinion of the MD-bridge program. The MD-bridge program received exceptional positive feedback and recognition of their great value compared to other programs expressing their opinion over the whole period of the program. To express their gratitude for Galen's crucial role in the MD-Bridge program Maastricht University gave him the Maastricht International Mentorship Award, in recognition for his constant efforts to involve Maastricht medical students in research. Personal experiences The focus of the MD-bridge program went beyond scientific output. Just as important was the personal experience and personal development of the participants. Table 1 shows that for almost all participants it was very stimulating to be in a different environment than the home institution. Participants felt that it significantly contributed to their personal growth, independence and feeling of achievement. In addition, for some participants it led to careers in foreign countries in medical practice or further research, like obtaining a PhD. To complete the MD-bridge experience, Galen, as the editor-in-chief of the Journal of Electrocardiology, encouraged participants to also act as peer-reviewers for the journal. Potential improvements We asked participants about potential improvements to the MD-bridge program and the inherent challenges of an
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international collaborative research program for students. To have only one main mentor at each institution can be challenging if the interaction between the student and the mentor for effective interaction and productivity is not optimal. In most cases these issues were resolved by finding a different mentor for the student allowing the student to continue his/her research project. Other challenges were that it was not always possible for 2 or more students to go together and support each other during the experience abroad. Also more preparation before starting the project abroad was considered useful mainly in the earlier years of medical school. This is not necessarily a challenge of the program itself but maybe more of their stage of medical education in general. Overall, participants felt that the program should be expanded to include other institutions as well.
Discussion This article gives an overview of an exceptional mentoring program exclusively designed to introduce students into the concept and performance of their own authentic research. A large majority of students that attended the MD-bridge have rated their experience as highly positive in terms of educational merit, scientific output and contribution to their personal and professional development. Since the primary goal of this program consisted of the student's achievements, this MD-bridge can be termed a successful program. Throughout his research career, Galen noticed that education at universities was mainly focused on training students to be good doctors instead of also becoming good researchers (something he called “studentosis”). Medical schools were (and for the majority still are) interested in teaching students information, and not teaching students how to perform research. This was in conflict with Galen's perspective of the value of clinical research in the students' medical curriculum. It is important to emphasize Galen's ideas about mentoring. Often research projects have already started, and participating students fulfill the mentors' requests. This is a way of “passive” participation. In Galen's opinion, the focus had to be on coaching and mentoring the student to design their own research project and go through the whole scientific process from idea to study design, hypothesis generation, data acquisition, data analysis and eventually leading to the development of a scientific manuscript that could be submitted to a journal for peer-review and publication. Much emphasis was put on the concept of students taking leadership of a research project. Galen often used the metaphor of a bus driver (representing the student) who is the one to decide which passengers (representing the co-authors) are allowed on the bus (representing the research project) and has the leadership in steering the bus to its final destination (representing publication of a manuscript). Furthermore, it was key that the research-pupils had to provide themselves with research resources, irrespective of what kind of resources these would be (i.e. prospectively collecting data or connecting with other researchers to be able to use existing data). Galen, using his broad scientific network, facilitated this process; however, it was for the student to decide who could finally be included as a co-author. In addition, the concept of data sharing fit well
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within Galen's view doing research. This so-called “tradebarter-system” could be, in his opinion, a solution for the often rigid and polarized attitude which is common in the scientific world and nowadays seems more present than ever before. By collaboration and sharing of data, research outcome (and thus patient care) could be dramatically improved in terms of efficiency, time and cost effectiveness. Thus, in summary, true mentoring means focusing on the individual and helping them to develop themselves. Another very important aspect of the MD-bridge was that students had to travel to Durham in order to optimally benefit from the interactions with Galen. This meant that students had to leave their safe, familiar home environment and were left to themselves to a great extent, asking for investment in self-development eventually resulting in independence and autonomy. Since these characteristics are key elements of the research philosophy of Galen, students were challenged in a double sense to work on their independence and leadership, both in research as well as their personal lives. Needless to say, this demanded a lot of courage from the students in the first place. Practically, Galen, along with his ECG-Core Laboratory secretary Mrs. Kathy Shuping even facilitated the research time by supplying addresses for housing and contacts with the International Student Office of Duke University in order to settle all formalities involved with visiting the United States as a student. Despite the fact that the majority of participants submitted a positive rating of the MD-bridge program, there were some cases in which the program did not succeed for various reasons. In case of a troubled interaction between student and mentor or stagnation of study progress due to data problems or collaboration errors, all efforts were spent to search for alternatives to eventually fulfill the primary goal of the program. Examples of these alternatives are transition to another local or at home mentor or switching to other research sources. Conclusions and future perspectives With Galen's impressive career of mentoring students, including the 23 MD-bridge program participants, he has left behind an amazing concept of self-development in research and personal life. The successes of the MD-bridge prove that it is possible for students to be young investigators during or just after medical school and that it has the potential to contribute to developing meaningful skills and noteworthy careers. Collaborations between international universities, such as the MD-bridge, are feasible and should be embraced by other institutions. References [1] Maastricht University. Faculty of health, medicine and life sciences. at https://www.maastrichtuniversity.nl/about-um/faculties/facultyhealth-medicine-and-life-sciences. [2] Duke Clinical Research Institute. athttps://www.dcri.org/. [3] Davis III TH, Wagner GS, Gleim G, Andolsek KM, Arheden H, Austin R, et al. Problem-based learning of research skills. J Electrocardiol 2006;39:120–8. [4] Majidi M, Kosinski AS, Al-Khatib SM, Lemmert ME, Smolders L, van Weert A, et al. Reperfusion ventricular arrhythmia 'bursts' in TIMI 3 flow restoration with primary angioplasty for anterior ST-elevation myocardial infarction: a more precise definition of reperfusion arrhythmias. Europace 2008;10:988–97.
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