www.nhsbsa.nhs.uk).Should I start an intercalated degree?
Choosing the right intercalated degree
Finding a programme and applying
Getting the most out of research projects
‘Intercalating’ is an opportunity to obtain a standalone qualification by taking a break from your usual medical studies. The qualification is normally a BSc degree in a medically related subject, completed in 1 year. Approximately a third of undergraduates undertake an intercalated degree in the UK. Intercalating means you will lengthen your course but qualify with two degrees.
There are numerous choices available for what you want to spend months on researching, categorized into the following:
• Laboratory projects: involve molecular or animal research.
• Clinical projects: based in hospitals collecting data or samples from patients.
• Library-based projects: retrospective and use secondary sources to compile a report (e.g. history of medicine).
• Clinical audit: a quality improvement process in which you compare data you collect on patient care against explicit national guidelines and implement a change to improve service provision.
• Grant proposal and study design: gives you the opportunity to compile a commercial proposal to submit to an organization to obtain funding for a project.
• Other projects: may include a poster presentation, coursework, team assessments, and vivas, depending on your intercalated degree.
• To explore your personal interests: the medical curriculum covers a breadth of topics, with limited time and opportunity to delve into a particular subject. Intercalating enables you to study an area of interest in far greater depth by learning about current thinking or conducting focused research.
• To experience a particular field: perhaps you fancy yourself as an expedition medic, or aspire to change public policy? From global health to healthcare economics, intercalation can provide an early opportunity to discover niches outside the mainstream. A scientific degree will provide a good introduction into academia, clinical governance, and advancement of education and medical literature. A BSc is the first step to a higher degree such as a Masters and a Doctor of Philosophy (PhD/DPhil).
• To gain new transferable skills: all programmes will significantly enhance your ability to effectively communicate your findings, review literature, and analyse critically. These skills are invaluable throughout your career—doctors need to evaluate evidence in any branch of medicine to offer optimal patient care.
• For careers in academic disciplines: participation in research is becoming increasingly crucial for trainees pursuing competitive specialties, such as surgery and academic medicine. Intercalated degrees may confer an advantage to enhance your CV as an undergraduate. An intercalated degree can boost your career prospects and counts towards extra points for your job applications.
• Academic achievement: your research could lead to significant achievement on your CV, portfolio, and job interviews if:
• it gets published in a peer-reviewed journal on the PubMed/MEDLINE database that can be accessed all over the world
• it gets accepted into a regional, national, or international conference for you to present your research findings
• it gets published as an audit in your local hospital
• regardless of the outcome and if your work does not get published in the worst-case scenario, you will always have your thesis with your name to add to your portfolio.
• For a hiatus: many medics report that intercalation broke up their course with a refreshing chance to enjoy an altogether different type of study. It is a nice break from strenuous clinical studies and rotations, and a chance for you to feel rejuvenated. Also, depending on the intensity of your chosen course and research project, you will find yourself having more spare time than when on clinical rotations to pursue your extracurricular activities.
• Post-nominals: are a perk upon satisfactory completion of your intercalated degree (e.g. BSc Hons, Master of Science (MSc), etc.)
• Travelling: may become an option if:
• you choose to do an external intercalated degree (outside your university) giving you an opportunity to spend time in another city and campus for a year making new contacts and friends
• some universities offer you the chance to carry out your research project abroad, such as in Tanzania for infectious diseases or Japan for gastric cancer.
Since intercalation is compulsory at some universities, students elsewhere might feel compelled to follow. Do not start a perfunctory degree! Make sure you are genuinely keen to spend a year engrossed in a particular subject to enjoy the challenges and rewards a wisely chosen one brings.
• Expectation: your supervisor may have forgotten what it was like being a medical student and may have far too many expectations from you. You must recognize your limitations and do not hesitate to ask for help and guidance from your supervisor. You will become more comfortable with research as you gain experience.
• Cost: you will be charged for an additional academic year so make sure that you are able to afford your tuition fee (up to £9000), rent, and living expenses. It is wise to seek alternative sources of funding such as internal and external scholarships and bursary schemes from the National Health Service (NHS) Business Service Authority ( www.nhsbsa.nhs.uk).
• Lectures: if you did not enjoy your time in preclinical and biomedical lectures, then bear in mind that the majority of your BSc will consist of attending lectures, sometimes for the entire day. Besides didactic lectures, there will an array of other activities including tutorial discussions, seminars, and team presentations.
• Project duration: there is no guarantee that you will be able to complete your project within the allocated time which means that there is no guarantee of journal publication or conference presentation. However, you can always try to complete the project during your vacations afterwards and try to publish then. Under a fifth of British undergraduates submit their research to journals.
• Extra study: it is an additional year and will prolong your time until graduation. However, an intercalated degree will work in your favour when applying for competitive jobs.
• Supervision: if your supervisors are full-time clinicians, you may not be given as much dedicated time for supervision compared to those who are full-time researchers. You are expected to be dynamic, work independently for most of the time, and figure out solutions to any rate-limiting steps. It is more likely that you will complete your project in time, present your findings at conferences, and publish your thesis if you are closely monitored and effectively guided by a hands-on supervisor.
• Funding: if your project budget runs over, then you may need to pause your research until more funding can be arranged which is a luxury that you cannot afford in the short time allocated before the submission deadline for your dissertation.
Hundreds of intercalated programmes are available across the UK. This might seem daunting, but degrees can be narrowed down easily to suit your preferences by systematically considering your criteria.
Begin by selecting a course according to your personal circumstances. External intercalators should consider the distance from family, friends, and your medical school. It is worthwhile finding out if you are expected to return during the year, and the financial and logistical feasibility of finding new accommodation and travelling.
Completing a degree in 1 year is intensive and demanding compared with the rest of the medical course. There is greater reliance on self-directed learning, with an increased scope for original thought, and often a student-selected component or project to steer in your own direction. It is therefore worthwhile searching for a subject that you feel passionate to pore over!
Will ultimately decide the classification of your degree, so determine which methods will be used (MCQ, essays, presentations, viva voce, dissertation) and their weightings. The overall result might depend on submitted coursework, end-of-year examinations, or a combination: play to your strengths.
For independent components and projects, students are customarily assigned one or more supervisors who are university staff members or clinicians. You could be engaged in a project under their supervision for months, so finding someone with whom you can develop an effective working relationship is important. If you have found a degree subject and project that interests you, contact your potential supervisor to arrange a visit. Communication is key: if they do not seem open and approachable, you can investigate alternatives. Additionally, inquire about the welfare resources accessible at your host institution while you are intercalating. Some students occasionally suffer unforeseen events requiring mitigation, which may be complicated by living away from your familiar support network and your GP.
Some master’s programmes leading to the award of MSc, Master of Research (MRes), etc. do accept medical students, but most require you to have completed 4 years of your main degree to be eligible or an intercalated BSc first. They often have term dates incompatible with the medical course, requiring an academic leave of absence. Beware that entitlement to future funding from Student Finance may be affected according to an equivalent level qualification rule.
www.intercalate.co.uk is a useful reference guide listing intercalated courses. It has a geographical search function and maintains a comprehensive database of individual programmes.
There is a growing number of alternative subjects to study as an intercalated BSc which are not related to the conventional specialities. Doing an intercalated degree in a non-conventional subject will showcase your talent and versatility and give you a competitive edge. A few contemporary subjects include
• health management (Imperial College London)
• healthcare ethics and law (Birmingham and King’s College)
• philosophy, medicine and society (University College London).
The most common intercalated degree at medical school is a BSc. Oxford and Cambridge graduates have their traditional BA automatically upgraded to Master of Arts (MA). A BMedSci is otherwise offered at Birmingham, Edinburgh, Nottingham, Sheffield, and Queen Mary’s (Barts and The London School of Medicine and Dentistry).
You will be given several lectures throughout the year about how the system works and which choices you have at your university. You will also be told about the content and modules available for each intercalated degree in more depth. Your university intranet should have a dedicated section on intercalated degree options with lectures from previous years.
Some may have the opportunity to undertake an intercalated degree at another institute, depending on the following:
• Subject choice: if your preferred subject is already offered internally, it is unlikely that you will be permitted to study that subject elsewhere.
• External university: select universities offer intercalated degrees to external candidates depending on spaces available, your previous exam performance, and possible interviews.
• Permission: your university has full discretion to grant you an academic leave of absence depending on your exam performance and professional conduct.
Your university may have internal awards available. Other organizations offer grants and bursaries—particularly Royal Colleges and charitable research organizations.
(See 
‘Clinical research’ pp. 1024–1027). Clinical research is broadly defined as involving human subjects with the goal of understanding and improving the diagnosis, treatment, and management of disease. It aims to inform clinical guidance by generating knowledge about best practice. Such research opportunities are by no means confined to intercalated degree courses—there are many ways for motivated medical students to get involved in elective or extracurricular projects.
Medicine is an evidence-based profession, and conducting research will equip you with a transferable and valuable skill set, even if you are not considering an academic career. Formulating questions, appraising literature, and understanding the methodology and ethics of science are competencies expected of doctors by the GMC. Research projects furthermore provide experience in communicating results through presentations and writing. If you are passionate about a particular specialty, getting involved at the forefront of understanding will allow you to engage and network with distinguished leaders in the field. Academic clinicians are often eager to teach, inspire, or even mentor students who approach their area of interest with enthusiasm.
Successful research projects open opportunities to present your findings at conferences or achieve authorship of a journal publication. This rewarding endeavour involves a large amount of effort and a small amount of luck, but will embellish your CV, and confer additional points on application to the Foundation Programme. Prestigious scientific breakthroughs have been initiated by students of medicine throughout its history. Charles Best, a Canadian medical student, successfully treated a diabetic patient after isolating insulin from pancreatic islets, which were first identified by German medical student Paul Langerhans. Your contribution could ultimately have a far-reaching impact on patients!
Primary medical research generates novel and original data from laboratory or healthcare settings. Laboratory projects may be classified as ‘wet lab’ (experimenting on biological tissue) or ‘dry lab’ (involving computational modelling and analytics). Secondary medical research involves gathering and analysing existing data, e.g. by systematic review and meta-analysis.
Weigh up your preferences carefully as it can be quite awkward if you change your mind halfway through. You will be spending at least 3–4 months doing this day in and day out. Every researcher encounters frustrations when delving into the unknown. Browse the latest copies of journals in the library in order to appreciate examples of research currently trending in your areas of interest.
Intercalated degree students will often be offered a list of upcoming projects in various departments and with named supervisors. Your principal supervisor will usually be the expert in their field, renowned and well published. Your principal supervisor will be the person you report to and who will sign off work. Since he or she is the head of a research department too and extremely busy, you may be given a day-to-day supervisor who will supervise you throughout the entire undertaking, from planning to publication.
Begin by searching the departmental directory of your university and teaching hospital websites for profiles of consultants and principal investigators (PIs) by area of expertise (a PI is a scientist charged to lead a particular research study). Institutions will usually maintain web pages containing their research interests, publications, and contact details. Alternatively, publication records can be sought by looking up your prospective supervisors by name on PubMed. Make a list of all those whose work is aligned to your objectives.
After identifying prospective supervisors, send a formal email to each, introducing yourself and expressing your interest in working with them. Sending multiple queries simultaneously is acceptable providing you do not promise any commitment at this stage. Follow up all positive replies by trying to arrange a face-to-face meeting at the supervisor’s convenience, and otherwise offer a telephone call. If they have a personal assistant, do not hesitate to contact them to confirm your availability. Be persistent in chasing up pledges, which can easily get lost among the competing demands on researchers’ time.
Prepare thoroughly before meeting supervisors for the first time: they will expect enthusiasm, knowledge about their own research, and broad ideas of what you hope to accomplish. Ensure plans remain realistic by discussing your role openly and explicitly explaining your timeframe and availability to the supervisor. Finally, request details of former students under their guidance. In turn, speak to them for recommendations, and try to find out if previous projects yielded any presentations or publications.
The only time you may be expected to find a supervisor is if you have organized a project by yourself and one that was not initially advertised through the medical school. In this case, you need to also provide a research proposal, sources of funding, and ethical approval to the medical school before starting the project. Hence, it is much easier to choose an advertised research project. It is wise to hold at least weekly meetings with your supervisor to discuss your latest research findings and so that your progress can be consistently monitored. This will also minimize the risk of straying away from a high grade.
Not only do you have to account for the expenses of an additional academic year of undertaking an intercalated degree, you also have to appreciate that research does depend on available funding. If you sign up to an advertised research project, then both ethics and funding may already have been arranged by your supervisor before you start. When joining an existing project, the cost of your contribution will usually be absorbed under an existing grant. Internal scholarships may also be offered in open competition. However, securing additional funding can widen the horizon of your research, and represents a prestigious accolade in its own right. Many organizations and charitable trusts offer bursaries to competitive medical students undertaking vacation projects, electives, and intercalated degrees. Forward planning is essential since applications for these awards often open just once per year, requiring full details of your intended project as well as a written reference or input from your supervisor. Some organizations offering scholarship include the following:
• The Association for the Study of Medical Education (ASME) is available for students doing projects and degrees in medical education worth £300 ( www.asme.org.uk).
• The British Association of Dermatologists offer up to £3000 ( www.bad.org.uk).
• The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) may support undergraduates with up to £500 ( www.bapras.org.uk).
• The Royal College of Surgeons of England is offering an intercalated BSc degree in surgery or surgical-related area and will review each project individually ( www.rcseng.ac.uk/standards-and-research/research/fellowships-awards-grants/awards-and-grants/medical-student-awards/intercalated-bachelor-science-degree/).
• Amgen Scholars provides full funding for undergraduates to participate in research opportunities at world-class institutions across the globe ( www.amgenscholars.eu).
• The Wolfson Foundation offers support for intercalation projects. Applications must be made via your institution—enquire within your medical school for more information ( www.wolfson.org.uk).
• The Carnegie Trust is open to Scottish students in their third year. Applications must be made via your institution for 2–8-week projects ( www.carnegie-trust.org/schemes/undergraduate-schemes/vacation-scholarships.html).
• Money for Med Students is the website of the Royal Medical Benevolent Fund and is laden with research funding opportunities ( www.money4medstudents.org).
• The UK Medical Student Association (UKMSA) lists a wealth of organizations offering specific research opportunities and funding ( www.ukmsa.org/research/studentshipsandfunding).
Sometimes, funding can be applied for from external organizations which also offer their own research projects. In this case, supervisors and ethical approval should usually be arranged prior to your involvement. As it would be an external research placement, you ought to seek permission from your medical school and check eligibility criteria. The advertised project may start later than internal projects in which case you will have less time but be expected to produce high-quality research, a presentation, and a thesis by the set deadline regardless. The organizations in Table 5.1 may be of some help.
Table 5.1 Organizations for placements
| Subject | Association | Website | Duration | Funding |
| Biochemistry | Biochemical Society (BiochemSoc) | www.biochemistry.org |
6–8 weeks | £1600 |
| Biomedicine | Wellcome | www.wellcome.ac.uk |
6–8 weeks | £1520 |
| Bioscience | Biotechnology and Biological Sciences Research Council (BBSRC) | www.bbsrc.ac.uk |
10 weeks | £2500 |
| Fertility | Society for Reproduction and Fertility (SRF) | www.srf-reproduction.org |
8 weeks | £1520 |
| Microbiology | British Society for Antimicrobial Chemotherapy (BSAC) | www.bsac.org.uk |
10 weeks | £1800 |
| Microbiology | Society for General Microbiology (SGM) | www.socgenmicrobiol.org.uk |
8 weeks | £1880 |
| Pathology | Pathological Society (PathSoc) | www.pathsoc.org |
6–8 weeks | £1500 |
| Physiology | Physiological Society (PhysSoc) | www.physoc.org |
6–8 weeks | £1200 |
| Science | Nuffield Foundation | www.nuffieldfoundation.org |
6–8 weeks | £1440 |
| Science | Medical Research Scotland | www.medicalresearchscotland.org.uk |
6–8 weeks | £2000 |
Whatever your chosen discipline, the independent work undertaken while intercalating can be disseminated as abstracts, presented at conferences, and even published in peer-reviewed journals. Conferences often give awards for the best poster presentation delivered by a medical student, and there are numerous prizes available for essays and original research by professional organizations representing medical and surgical specialties.
Stubbs TA, Lightman EG, Mathieson P. Is it intelligent to intercalate? A two centre cross-sectional study exploring the value of intercalated degrees, and the possible effects of the recent tuition fee rise in England. BMJ Open 2013;3:e002193.
In clinical research, you will inevitably work with health records, or information which can identify people, or which would enable their identity information to be retrieved. It may be your first time with authority to access large volumes of confidential information, and it may be tempting to save and backup your hard work as usual. Beware that clinical data is different. Retaining, copying, and transferring sensitive data (both paper and electronic) is subject to strict legal requirements as well as local trust policies, known collectively as ‘information governance’. Consult your supervisor and governance department at your hospital for advice before you start.
Everyone involved in the conduct of clinical research should receive GCP training commensurate with their roles and responsibilities, to ensure the rights, safety, and well-being of participants are protected. Practically, GCP teaches the laws, frameworks, and guidelines which govern the set-up and conduct of trials, and will empower you to consent and recruit participants. You can either attend the courses or complete the online version.
• Choose a topic based on your genuine personal interests.
• Seek supervisors with a proven track record of mentoring undergraduates.
• Ask if funding is already in place for the project. This will save many headaches. If not, then apply for funding as soon as you have confirmed a project. You must appreciate that all applications do not receive funding. Additionally, there may be numerous stages of applications ahead of you which all take plenty of time!
• Diligently compile your findings soon after acquisition.
Presentations serve to share information of value with others in the medical profession and scientific community. Posters and oral talks are the two most common methods for communicating your findings face-to-face. By presenting, you will receive helpful feedback from members of the audience, exchange ideas among researchers familiar with your topic, and meet like-minded potential collaborators.
Besides conferences, research can be showcased at your medical school, pitched to the faculty where it was conducted, or presented at a local hospital trust. Your CV will be enhanced by any of these activities. Conferences will invite exhibitors to submit an ‘abstract’ in advance (a short, written summary of your work which lets them decide if your research matches their interests).
• Organizers screen received abstracts to confirm your project is relevant to the event, in which case you may be offered a poster or an oral presentation.
• Abstracts form the beginning of published journal manuscripts.
• Abstracts are ‘indexed’ by libraries and databases, meaning users can search their content to retrieve relevant literature.
In every case, they are paramount to capturing attention.
Abstracts are traditionally structured into certain headings and limited to 250–350 words or less.
This section is often the shortest, and contextualizes the overall purpose of your project by introducing the rationale for investigation in as few as two sentences:
1. Summarize what is already known about your topic—cite previous studies as references.
2. Explain what is unknown and outline how your project adds to this existing knowledge.
You should reduce jargon to a non-technical level that your audience will understand.
States exactly what your project intends to measure and discover—bullet points are appropriate. Readers will refer to your aims when deciding if your methodology is suitable, and if your results indicate success.
An objective description of what you did to obtain your results. Not every intricacy needs to be included in this section. To decide what to exclude, list each step of your experimental process from start to finish. Now ask whether knowing each detail could affect the conclusions a reader draws from your study. For example, it may not be relevant to mention the make and model of a prosthetic heart valve for a project comparing surgical vs medical management of aortic stenosis, but it would be important if comparing outcomes from two different manufacturers. Key parameters to expand include:
• population—the participants and how were they selected
• intervention/indicator—the tests or procedures under scrutiny
• comparator—any controls or alternative strategies or exposures
• outcome—how the consequences were measured and analysed.
Readers perusing an abstract will be most interested to learn about the findings of your study. Therefore, this section should comprise the longest part and quantify as much relevant detail as the word count permits. For example, ‘5-year mortality rates differed significantly between medical and surgical groups’ is better expressed as ‘The 5- year mortality rate was higher in surgical than in medical patients (15% vs 12% respectively, p <0.05)’. Always provide the mean value of outcome measures and their p-values, as in this example. Test statistics need not be included for comparison studies; however, the r-value should be added in correlation studies.
Can be simplified to three elements:
1. Based on the results, derive take-home messages related directly to the original aims and objectives.
2. Without reiterating any numbers, highlight the implications of the outcome measure (only the results section should contain data).
3. Customarily end with an opinion or perspective on the importance of the findings for the field.
A poster presentation is a visual summary of your entire project. It can be thought of as a graphical version of an abstract: designed using a computer program such as Microsoft PowerPoint, printed on A1 or A2 large-format card, then discussed face-to-face with judges at an academic event. Posters are made for exhibition at specific meetings after the organizers have approved a pre-submitted abstract of your research. There may be over 50 on display at a national conference, with prizes available for the best (scored on both your content and conversation). Make sure you check what the poster size should be before designing it, especially whether it is portrait or landscape as the conference boards will be set-up accordingly.
Before creating a poster:
1. Check with your collaborators that you may present the group’s shared findings and intellectual property.
2. Confirm how their names should be credited on the poster.
3. Ask if they have any conditions or suggestions for the design.
Include the names of every colleague who contributed to the project on your poster and involve them throughout the process—all co-authors must approve your submission, and may offer you use of digital diagrams and figures they have designed previously.
You must adhere to the size and orientation specified by the conference (e.g. A1 portrait). Judges may otherwise disqualify you from the competition, or organizers may altogether disallow you from presenting! Using Microsoft PowerPoint, the poster can be created on a single slide, set up by clicking on the ‘Design’ tab and inputting dimensions manually through ‘Page Setup’.
Ask your supervisor to see examples previously produced by researchers in your team (see Fig. 5.1 for an example). Identify the audience and tailor your content to be as accessible as possible to delegates. For instance, conferences about a niche subject might favour a focus on the exact details of your methods, whereas an overarching explanation will benefit generalized meetings. Will the posters be marked for a competition, and by whom?
• Include a title, list of author names, and all the aforementioned sections expected in an abstract: background, aims/objectives, methods, results, and conclusion/discussion.
• Components can be laid out vertically in columns, or horizontally in rows, whichever makes your information flow most intuitively.
• Include enough text to provide a basic understanding of your project, but not so much that readers feel bored. Remember you can expand and explain further during discussion with judges.
• Dark font on a light background is most legible.
• Use abbreviations: familiarize your reader by iterating the full name on first use (with the abbreviation in parentheses).
• It is similarly acceptable to re-christen long scientific names (e.g. ‘coenzyme Q10’ becomes ‘CoQ’).
• Exploit maximum use of figures and diagrams to allow the reader to visualize concepts—a picture paints a thousand words—even your methods can be summarized in a flow diagram.
• List references and acknowledgments of funding.
• Add your email address so people can subsequently contact you with afterthought comments, questions, or proposals.
Ask colleagues to review and critique your draft; friends and family without a medical or scientific background are an excellent source of feedback on aesthetics and clarity. Once you and your supervisor are happy, get the finalized version printed professionally. Printing companies will offer several options:
1. Lamination bonds a thin film over the paper to give a gloss finish (like magazine paper) or matte finish (which minimizes glare).
2. Encapsulation will protect your poster from creases, fingerprints, and scratches by encasing the paper in plastic.
Additionally, print several copies of your poster on ordinary A4 paper for interested peers to take away.
Fig. 5.1 Example presentation poster. Reproduced with permission from Dr Kapil Sugand (co-author) and MSk Lab, Imperial College London.
• Practise, practise, practise presenting your poster orally to anyone who is willing to listen—usually for 5 min, with a further 5 min for questioning—keep strictly within time limits.
• If you are unsure how familiar your audience is with your subject area, ask them before you begin. It is safer to assume zero prior knowledge and an infinite capacity for intelligent thought.
• Be prepared to boil down your research in a few minutes and be able to summarize your project in one concise sentence.
• Verbal discussion may influence the judges as much as the poster.
• Invite questions from your audience at the end or throughout.
• It is not merely what you say, but how you say it. Judges will be impressed by enthusiasm while demonstrating your work.
It is a common misconception among medical students that co-authoring primary medical research is the only way to get published. Although novel findings are attractive to many journals, secondary medical research offering novel insights into existing data are held equally dear. Most projects are worth reporting to the scholarly community of scientists and clinicians if you can devote a few hours each week to the cause.
1. After the completion of any project, strive to analyse results, draw conclusions, and contextualize the importance of findings as soon as possible. The world of research is vulnerably fast-moving and filled with breakthroughs named after investigators who communicated—not discovered—them first.
2. Conduct a thorough literature search to survey where your work fits within the landscape. The most popular resource is PubMed ( www.ncbi.nlm.nih.gov/pubmed/), a free website for searching MEDLINE (the National Library of Medicine database of clinical and healthcare abstracts and citations). In case MEDLINE is saturated with papers on your topic, consider writing about it from a different, unique perspective.
3. Re-read your supervisor’s most recent publications to appreciate an appropriate scientific template and writing style. Proceed to compose an academic manuscript from your own project. This endeavour can be copiously time-consuming, ideally undertaken by dedicating a couple of hours each week to drafting. You might like to enlist the help of experienced PhD students for guidance.
4. In addition to your supervisor who will thoroughly understand the topic, ask another faculty member with whom you enjoy a good professional relationship to critique the draft.
5. Identify journals which are likely to accept your paper: there are currently over 5000 indexed by MEDLINE; your supervisor will be best placed to suggest the most suitable. Journals are ranked by ‘impact factor’: a proxy measure reflecting their relative importance within a field. Papers must be submitted to one journal at a time to be considered for publication, usually to those deemed more important, before those with lower impact factors.
6. Each potential publisher maintains a website containing instructions to prospective authors. Ensure these criteria are strictly met by formatting articles accordingly; otherwise your submission will get rejected outright. Including a cover letter can outline the importance of your article to the journal’s readership. Some editors may kindly return feedback recommending improvements.
Rarely will any journal commit to publishing your finished product without recommending multiple revisions to the article. Commonly, ideas are rejected altogether. Do not be put off: present your idea to another journal—you are likely to learn from criticisms.
• Always credit other people's work honestly and properly using references.
• Any article that contains personal medical information about an identifiable living patient requires their permission for publication by obtaining prior written consent.
• Ensure any images and figures are included at a high resolution of at least 300 dots per inch.
• Stringently check spelling and grammar by proof reading.
• Ensure that you abide by the in-house formatting guidelines for each journal listed on their website—otherwise the submission will be automatically rejected and sent back to you.
Once an article has been submitted, it will firstly be scrutinized for publication by an editor. Promising papers are then constructively forwarded to further editors or external peer reviewers for second opinions. If these adjudicators decide to pursue your article, they may specify alterations to be made before acceptance (see Fig. 5.2).
Fig. 5.2 Published journal article. Reproduced from Acta Orthopaedica under CC-BY-NC-ND 3.0 licence, and permission from lead author, Dr Kapil Sugand. © Nordic Orthopaedic Federation.
You may get the chance to experience basic science laboratory research during a special study module, an intercalated BSc, or even as an extracurricular activity. It is an opportunity not to be missed, and offers many invaluable skills: ‘wet-bench’ techniques such as cell culture or Western blotting, critical and independent thinking, objective critique of scientific literature, basic statistics, etc.
This is the branch of pathology dealing with tissue diagnosis of disease based on gross, microscopic, molecular, chemical, and immunological examination. It encompasses the following branches:
• Histopathology—the study of changes in tissue caused by disease:
• Histochemistry is the science of staining tissue sections for diagnosis.
• Immunohistochemistry is the science of detecting the presence, abundance, and localization of antigens and proteins using antibodies.
• Immunofluorescence tags a coloured dye molecule to an antibody.
• Cytopathology—the study of disease at cellular level:
• Specimens are collected from smears or fine-needle aspirates.
• Pathophysiology—the study of disordered physiological processes as a result of disease.
• Electron microscopy—uses high-resolution magnification at cellular level.
This is the branch of pathology dealing with microscopic and macroscopic analyses of internal bodily fluids (e.g. blood, urine, and semen). It consists of the following branches:
• Microbiology: the study of microorganisms; can be categorized into immunology, bacteriology, parasitology, virology, and mycology. Cultures and sensitivities are also deduced.
• Chemistry: the analysis of serum or plasma constituents (e.g. renal function test), blood sugar, lipid profiles, protein and enzymes (e.g. liver function tests), toxicology (e.g. paracetamol overdose), and endocrinology (hormone profiles).
• Haematology: the analysis of red and white blood cells, platelets, and clotting function.
• Reproduction biology: for analysis of gametes.
• Genetics: the analysis of DNA and genetic data.
• Cytogenetics is used to deduce a cellular karyotype.
This is probably more important than the actual subject matter of the project, particularly for a short placement. You are unlikely to accrue much publishable data in a matter of weeks or months, yet fostering a good working relationship leads to future opportunities.
Do not focus so hard on finding a placement with the most influential professor that you overlook the need for someone with the time to supervise you on a day-to-day basis. Being unsupervised in a new and alien environment can be a lonely and frustrating experience. If possible, visit the lab (and supervisor) before starting and find out who will be directly in charge of you. You are looking for a lab with research assistants or PhD students who will take the time to talk you through new skills rather than leaving you floundering.
You are unlikely to have much say over this at an early stage. Often a supervisor will have a set project in mind to answer a specific question, and you will not be expected to have much creative input at the beginning. It is important, however, to have a basic grasp of the context of your work; ask your supervisor to recommend some relevant review articles to introduce you to the field. You will certainly gain expertise in the field of study if you take the initiative to conduct a short literature review. This may also act as the basis of your publication. You should also have a realistic expectation of what can be achieved in the time you have; if a technique takes 6 months to master, it may not be well suited to a shorter placement.
It would be unusual if a short period in the lab were to culminate in a Nature paper but do not let that stop you at least trying! However, it is useful to have something to show for your efforts, such as a poster presentation at a local conference or medical student forum.
You may decide that basic science is not where your future lies, which is valuable to know. Hopefully, however, you may be inspired to pursue a career in academic medicine, and your lab experience will give you some direction and useful contacts. Applications to the Academic Foundation Programme are competitive, and having spent time in a lab will stand you in good stead.
Relevant to every quantitative technique in medical research. Selecting the correct statistical tool is imperative for meaningful data analysis. A popular and uncomplicated statistics program is GraphPad Prism which offers a free 30-day trial and reduced rates for students ( www.graphpad.com/demos/).
Make an effort to attend lab meetings and journal clubs, and do not be afraid to ask questions! Much like clinical medicine, it is best if you clear any confusion sooner rather than later, especially when you will be expected to lead the management of a patient or a research project after you graduate. If you get the chance to present a paper yourself, it is a great learning opportunity. Similarly, your department is likely to run a series of seminars, which are well worth attending however far removed from your immediate field of interest.
Oral presentations (at meetings or conferences) and written communications (such as posters and submissions to journals) both require a great deal of skill. Much emphasis is put on the abstract, which should succinctly summarize both the context and content of your work. Assume your reader is an experienced scientist outside of your immediate field.
You will need a Home Office licence ( www.gov.uk/research-and-testing-using-animals) and local security clearance before working with live animals in research. These may prove prohibitive for a short lab placement, though postmortem work does not require a personal licence. Most animal research in the UK uses mice and rats, though other species such as primates, rabbits, fish, and farm animals are sometimes used. No investigators relish the prospect of animal research but most agree that it is a vital part of medical science. Even a brief exposure to this field will make you appreciate the measures in place to legislate and optimize the use of animals. Use common sense when discussing this outside of work.
This describes the techniques involved in growing and maintaining either primary cells (i.e. isolated directly from tissue) or cell lines (immortalized, genetically identical) in vitro. Typically, it takes days to weeks to achieve a population of cells ready for an experiment though doubling time can vary. You will become skilled at light microscopy in order to chart the progress of your cells and preparation of cell culture media and this is before your experiment has even started.
This is a rapidly evolving technology used to optimize spatial resolution and 3D imaging of tissues. Antigens of interest within a tissue or cell population are labelled using fluorescent antibodies, and are identified by the use of fluorescent filters and detectors. Provides anatomical/spatial and dynamic data. Particularly helpful alongside ‘reporter mice’ which are genetically engineered so that a specific antigen or cytokine fluoresces without further labelling.
This technique is used to quantify the concentration of antibody or antigen in a sample. It requires fastidious precision in pipetting and making serial dilutions for a reference curve but when used successfully provides robust and reproducible data. Gives a valuable insight into why some clinical tests take a long time to be reported!
Cells can be labelled with antibodies that bind to the cell surface or intracellular antigens, which then fluoresce when excited with light of a certain wavelength. This fluorescence is detected by sensors within the flow cytometer. For example, a fraction of human leucocytes could be stained with one colour for CD3 (T cells), another for CD19 (B cells), and a third for CD15 (neutrophils). This information can be used to quantify populations within a sample, or even to separate it into its individual components (cell sorting).
The field of genomic analysis is expanding at a staggering rate, and is frequently used to evaluate gene expression in thousands of different genes simultaneously. Such large data sets mandate a sophisticated grasp of bioinformatics and familiarity with computer programs such as R and Bioconductor.
Many labs work with infectious microorganisms such as bacteria (Salmonella, Escherichia coli, staphylococci) and viruses (HIV, influenza). They may be studied in vivo (i.e. injected into animals) or in vitro (cell culture). Unsurprisingly, this work is carefully regulated and the risk to the law-abiding investigator is very low.
This is used to amplify a small sample of DNA allowing for subsequent identification (e.g. of a microorganism, or a gene mutation) or quantification. Thermal cycling is used to melt, anneal, then amplify the DNA sequence in question. Extremely versatile and a good example of molecular biology in practice.
The quintessential lab technique both eulogized by sentimental professors and loathed by struggling PhD students! This is a semi-quantitative method of analysing proteins of interest, e.g. the presence of antibodies in a clinical sample or a change in protein expression under experimental conditions. Sodium dodecyl sulfate polyacrylamide denaturing gel electrophoresis (SDS-PAGE) is a frequently used method for separating proteins by gel electrophoresis.
1. Have a realistic idea of what you want to achieve in the given time. Many short projects do not end in meaningful data; this is not necessarily a reflection on you!
2. Keep an open mind. You will be surrounded by people from a different background, with different skills and interests to your own. Expect to learn from your non-clinical colleagues and they may do the same.
3. Persevere. Most experiments do not work the first time, and often a protocol needs to be repeated again and again before it is reproducible. Write fastidious laboratory notes so you can identify what worked or did not work.
4. Be a good colleague. If you use the last of a reagent or piece of equipment, ask someone how to replace it!
5. Share the knowledge. If someone takes in interest in you as a new starter, reciprocate when someone else joins the lab after you. This will clarify matters in your own mind and expose any gaps in your knowledge.
6. Ask questions. They are rarely as stupid as you fear they are, and often half the room is wondering the same thing!
7. Do not take short-cuts! If you have spent 10 days preparing a cell sample, don’t compromise your experiment by a sloppy assay or analysis.
8. Read! You will rarely have so much time available to scour PubMed for articles of interest. Look beyond the title, think what has this paper shown for the first time, and how would I have done things differently?
9. Have something to show for your time. This could be a poster in the medical school or at a local meeting, or a written report summarizing your work. This is a good exercise in scientific writing. Think about how you can describe your lab experience to enhance your CV.
10. Enjoy the freedom. Lab time offers an unparalleled opportunity to be your own boss. This gives you a chance to organize your time in a way that is not possible in clinical medicine. Finding out how you work most effectively is a valuable life skill.
‘Statistics are like bikinis. What they reveal is suggestive, but what they conceal is vital.’ Aaron Levenstein
It is said that with a good statistician, one could extract any desired result from a data set, and a vast array of statistical tests have been described for different conditions. As a medical student, you should have an appreciation of basic statistics, both in order to describe accurately any data that you may accrue yourself, but more importantly to understand and critique data that are presented to you.
• Mean: sum of data divided by number of data (average). Commonly used but influenced by outliers. Appropriate in ‘normally’ distributed data.
• Median: the middle value in numerically ordered data. Better suited to skewed distributions.
• Mode: most frequently occurring value. Does not represent data fully.
• Frequency: the rate at which an event occurs over a period of time or in a given sample.
• Normal distribution: a symmetrical ‘bell curve’ in which the mid-point signifies median = mean = mode (see Fig. 5.3).
• Parametric testing: based on the assumption that the distribution of the underlying population from which the sample was taken is usually normally distributed.
• Range: the difference between the largest and smallest data points.
• Standard deviation (SD): the spread of data from the mean (square root of variance). Very commonly used in conjunction with the mean.
• Standard error of mean (SEM): how accurately SD describes the data, i.e. reduces with increasing data points.
• Confidence interval (CI): a range in which 95% of data are expected to fall. Usually mean +/− 2 × SEM.
• Interquartile range (IQR): a quartile divides a data set into four equally sized parts. The IQR is the difference between the first and third quartiles, and hence describes the range of the middle 50% of a data set. Not greatly influenced by outliers. Often used alongside the median.
• Correlation: a relationship between two or more factors.
• H1: a proposed explanation requiring scientific experimentation to prove or disprove the theory
• H0: known as a null hypothesis which states that there is no relationship between measures and that all observations occur due to chance. This is used in more widely in medical research (e.g. lung cancer is not related to smoking). The null hypothesis can never be rejected, instead it is either accepted or not accepted.
• P-value: the probability of a result occurring by chance if the null hypothesis is true. Usually taken to be <0.05 (often represented as *). This is an arbitrary threshold liable to:
• Type I error (α): null hypothesis is incorrectly rejected or finding a result where none exists. Its rate is equivalent to the accepted significance level (5%).
• Type II error (β): when the null hypothesis is incorrectly accepted or failing to find an effect that is present.
In medicine, a type I error is considered to be more important than type II in that a positive finding is more likely to change practice than a negative; α should be less than β. This leads to:
• Power: probability that a test rejects the null hypothesis when the alternative is true (i.e. 1 − β). Usually 80–90%. Greatly influenced by sample size (n). Power calculations are done before an experiment or trial to determine what sample size will ‘power’ the trial to detect an effect. Hence a p-value <0.05 may not actually be significant if the sample size is too small. Beware that what may be statistically significant may not be biologically or clinically significant, and vice versa.
• Positive predictive value (PPV): the proportion of patients with positive test results who are correctly diagnosed.
• Negative predictive value (NPV): the proportion of patients with negative test results who are correctly diagnosed.
• Student’s t-test: probability of the difference between two data sets having arisen by chance. Can be paired or unpaired. Requires data to be normally distributed.
• Mann–Whitney U test: also known as Wilcoxon rank sum test. Used to detect statistical significance between data sets which are not normally distributed.
• ANOVA (or one-way analysis of variance): calculates differences between means of more than two groups (where multiple t-tests would increase type I error).
• Dependence: a relationship between two sets of data.
• Hazard ratio: similar to relative risk (RR) but useful when the risk information is collected at different times.
• Odds ratio (OR): the odds of an outcome (e.g. lung cancer) in conjunction with a particular variable (e.g. smoking) compared to without it. If OR = 1, exposure does not affect odds of disease; if OR >1, exposure is associated with higher odds of disease; and if OR <1, exposure is associated with lower odds of disease. Note does not imply causation! Risk ratio or RR are crudely comparable to OR.
• Number needed to treat (NNT): the number of patients required to receive an intervention in order to prevent one outcome. For example, triple therapy vs histamine antagonist in Helicobacter pylori eradication in peptic ulcer disease, NNT = 1.1 vs antibiotics vs placebo in prevention of infection following dog bite, NNT =16.
• Number needed to harm (NNH): the average number of patients who need to be treated with an intervention for a period of time to cause one adverse outcome.
• Absolute risk (AR): the probability of a specified outcome during a specified period.
• Absolute risk reduction (ARR): the decrease in risk between the intervention and control cohorts as a result of activity or treatment.
• Relative risk: ratio of incidence of disease in exposed individuals to the incidence of disease in unexposed individuals.
• Bias: a systematic error that causes deviation from the true value, may it be selection, measurement, or analysis.
• Continuous data: a set of data that can be measured.
• Ordinal data: consists of values or observations that can be ranked or belong on a scale.
• Nominal data: consists of items that are categorical (e.g. a set of measurements).
• Discrete data: categorized into a classification based on counts.
• Incidence: the number of new cases of a condition occurring in a population over a specified period of time.
• Prevalence: the proportion of people with a finding or disease in a given population at a given time.
• Likelihood ratio: the probability of a test result in patients with a specified disease divided by the probability of that test result in people without that disease.
• Stratification: categorizes individuals with common factors (e.g. age, sex, ethnicity) into classes (or strata).
• Sensitivity: relates to the ability of a test identifying positive results correctly (true positives).
• Specificity: relates to the ability of a test identifying negative results correctly (true negatives).
Microsoft Excel performs simple analyses and ought to be sufficient. GraphPad, Prism, and Stata are recommended for more sophisticated tests. SPSS and R are used for large data sets or complex analyses.
Fig. 5.3 Normal distribution curve. Reproduced from Ray, Sumantra, et al, Oxford Handbook of Clinical and Healthcare Research, 2016, Oxford University Press.
These resources may be of help:
• Peacock JL, Peacock PJ (2010). Oxford Handbook of Medical Statistics. Oxford: Oxford University Press.
• Peacock JL, Kerry SM, Balise RR (2017). Presenting Medical Statistics from Proposal to Publication, 2nd edition. Oxford: Oxford University Press.
• Petrie A, Sabin C (2009). Medical Statistics at a Glance, 3rd edition. Oxford: Wiley-Blackwell Press.
• Statistics in Medicine: www.onlinelibrary.wiley.com/journal/10.1002/(ISSN)1097-0258
• British Medical Journal (Endgames: Statistical Question): www.bmj.com.
• Statistics at Square One: www.bmj.com/about-bmj/resources-readers/publications/statistics-square-one
• Centre of Statistics in Medicine: www.csm-oxford.org.uk.