Summer undergraduate research: A new pipeline for pain clinical practice and research

Design and setting of study

This study was done as a pre-post cohort study and was intended as a descriptive study to generate preliminary findings about the PURE program, possible barriers to its intended function, and initial level of pain knowledge in the population where future participants will come from. The design of the study was based on a typical summer undergraduate research experience with a novel focus on 10-weeks of intensive pain research. In addition, all of our PURE fellows participated in off-site and on-site experiences with community members. Off-site, working with two different pain clinics, individual students spent time shadowing clinicians as they interviewed, interacted, and treated chronic pain patients. Clinical shadowing experiences have been linked to increased empathy with the patient condition and increased interest in post-graduate studies [18]. On-site at Duquesne, students had a group session with a pain psychologist from the community and separately a fibromyalgia chronic pain patient. The goal for these sessions was for students to be able to understand pain from both the clinical and patient perspective in an informal and relaxed atmosphere. In addition to these community partnerships, the PURE program also involved a monthly pain journal club, weekly pain textbook seminar, a community service project, process-oriented training sessions (e.g. poster making, abstract writing), a 6-week ethics session, and individual presentations at a regional poster symposium. In addition, all of our students travelled off campus to attend a regional pain research conference. The goal for this experience was to provide students with exposure to some of the best pain research in the area and world. Setting of study was Duquesne University, a research university in Pittsburgh, PA, USA.

Participants and participant selection

The study population were rising sophomores, juniors, and seniors from 4-year undergraduate universities and colleges in the United States. Participants applied for the PURE program through an online application process. Application materials included an academic transcript, two letters of recommendation, a resume, and a statement of goals. The applicants were asked to describe their specific interest in pain and their preferred research lab in the statement of goals. We received a total of 39 completed applications for the program including 30 external applications. Applicants were evaluated by a committee including individuals within the Duquesne pain community and outside. Applicants were based on a combination of factors including overall GPA, GPA in science courses, letters of recommendation, statement of goals, and availability of faculty mentors to host students.

Consent and ethical considerations

After enrollment in the PURE program, participants gave oral and written informed consent. All 10 students enrolled in the 2015 PURE program consented to participate in the study. Consent document included the following sections: purpose of the study, compensation (none for participation in the study), confidentiality, right to withdraw, and a statement of voluntary consent. Voluntary consent statement was as follows—“I have read the above statements and understand what is being asked of me. I also understand that my participation is voluntary and that I am free to withdraw my consent at any time, for any reason. Withdrawal from the study will in no way affect the educational services I will receive as a summer researcher at Duquesne University. Finally, I affirm that I am at least 18 years old. On these terms, I certify that I am willing to participate in this research project.” Risks associated with participation in this study were deemed to be minimal. As described below, all surveys were coded without personal information. This study was determined to be “Exempt” according to “US 45CRF46.101(b)(2): Anonymous Surveys—No Risk.”

Surveys

Statistical analyses

Evaluation of student responses for the “definition of pain” was done blinded to individual participant and whether the definition was from an entry or exit survey by two researchers. Rubric for scoring was developed de novo based on the International Association for the Study of Pain (IASP) taxonomy of pain definition “An actual sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” [20]. The maximum possible points on the rubric was 9. The highest value obtained from PURE fellows was 4.5. For the definition question, the score on the exit survey was divided by the entry survey score to determine a percent increase in score. This was analyzed by a 1-sample t-test to determine if students showed an increase or decrease in the accuracy of their definition. In addition, for the definition questions and other questions that were repeated on the entry and exit survey’s, student responses were evaluated using paired t-tests. Data are presented as mean ± SEM. All differences with a P < 0.05 were considered statistically significant.

Demographics

Students (n = 10; eight female; all GPA >2.5; variety of years in college) came from Duquesne University (n = 8) or two external “liberal arts” institutions. Duquesne students came from three different schools on campus (science, health science, pharmacy) indicative of the multi-disciplinary nature of pain research. All students reported strong qualitative support from their home institutions and previous research and academic mentors on entry surveys. To the question “On a scale of 1–5, how would you evaluate the quantity of academic interactions with your mentors at your home institution?” the average student response was 4.4 ± 0.2. To the question “On a scale of 1–5, how would you evaluate the quality of these interactions at your home institution?” the average student response was 4.4 ± 0.2. To the questions “On a scale of 1–5, to what extent did your home institution mentor encourage you to participate and help you find a summer research program?” the average student response was 4.2 ± 0.3. To the question “On a scale of 1–5, how well do you feel your home institution has prepared you in terms of conceptual and theoretical knowledge?” the average student response was 4.3 ± 0.3.

In addition, interactions with faculty members in the PURE were reported strongly positive and extensive on exit surveys. To the question “On a scale of 1–5, how would you evaluate the quantity of academic interactions with your mentors in the PURE program?” the average student response was 4.6 ± 0.2. To the question “On a scale of 1–5, how would you evaluate the quality of these interactions in the PURE program?” the average student response was 4.9 ± 0.1. To the question “On a scale of 1–5, to what extent did your PURE mentor help you set these goals?” the average student response was 4.5 ± 0.2. Students reported quality gains in technical knowledge related to pain. To the question “On a scale of 1–5, how would you evaluate the quality of technical expertise, in terms of conceptual and theoretical knowledge, you gained from the program?” the average student response was 4.6 ± 0.2.

Pain research

Students were placed in research labs working on some aspect of pain. All faculty involved were part of the Duquesne CPRC. This consortium includes faculty involved in basic science pain research (pain biology and pharmacology, pharmaceutics, medicinal chemistry, natural products chemistry, nanomedicine, molecular imaging, pain in aging), pain clinical practice, and pain education. In combination with all of the clinical exposure from the planned activities, students were exposed to basic science research into mechanisms of pain, how to treat pain with mechanical interventions, analgesic drug discovery, pain education research, nanoemulsions for pain drug delivery, and understanding pain circuitry from a biological perspective.

Pain journal club and didactic pain seminar

A solid understanding of primary literature and the current state of the field is important for young researchers. The journal club was presented by graduate students and faculty involved in pain research. Articles were chosen from a variety of fields and perspectives and sent to students 1 week before presentations. Presenters gave a brief background on the general topic and then broke down the paper and went through its main assumptions and results. Students were encouraged and asked to provide their input on these topics as well. This allowed students to be exposed to how literature can be evaluated and critically assessed. Sessions would typically end with a discussion about what the next steps in the research should be or how the paper might alter or affect their own research. In addition to this monthly journal club, PURE students were also encouraged to attend a didactic pain course run by PhD graduate students. In this informal course, a single graduate student went through chapters of Wall and Melzak’s The Textbook of Pain [21] each week. Consistent with expectations of learning from the journal club and course, didactic training significant improvements were seen in student’s “comfort with pain terminology” comparing entry and exit surveys (Fig. 1). Although students’ comfort with pain terminology increased during the summer, their ability to define pain did not significantly change (entry 2.3 ± 0.3 vs exit survey 2.8 ± 0.3 out of possible 9, paired t-test, P = 0.34; exit/entry score 142 ± 21 %, one-sample t-test compared to hypothetical “no change” value of 100 %, P = 0.08). Discussions during the journal club and in students’ research labs also likely contributed to increases in students’ “comfort…explaining pain and/or chronic pain to another researcher” (Fig. 1). To the question “On a scale of 1–5, how would you evaluate the effectiveness of the PURE/URP speakers/seminars?” the average student response was 4.5 ± 0.2.

Interaction with the clinical side of pain

In designing the PURE program, we wanted students to appreciate why they were doing basic science research. While part of the answer to this question lies in the specific research project that each student worked on, the bigger answer focuses primarily on the needs and experiences of individuals living with pain. To develop the skill-set and empathy necessary to interact with patients and other clinicians, students participated in three “clinical” activities. They shadowed pain doctors at a pain clinic, met informally at Duquesne with a pain patient, and had lunch with a pain psychologist.

For the clinical shadowing component of the program, students went individually or in pairs to one of two pain clinics in Pittsburgh, PA. Students spent ~4 h at the pain clinic where they observed doctor-patient interactions and pain intervention procedures. Both clinicians reported these events as positive experiences; “The students were eager, engaging, and interacted well with staff and patients” (e-mail conversation between BJK and clinicians). To the question “On a scale of 1 to 5, how would you evaluate the PURE off-site clinical experience visit?” the average student response was 4.9 ± 0.1.

For the on-campus visit with a pain patient, students were able to interact informally with a long-term (>15 year) fibromyalgia patient. This patient had been briefed prior to the session to establish appropriate boundaries and expectations. These boundaries were then shared with the students prior to the start of the session. During this informal 1-hour session, the patient described her experience living with chronic pain and her experiences interacting with various pain clinicians. The students were encouraged (by the patient) to then ask questions. One of the advantages of this situation compared to patient interactions in a formal clinic is the freedom that the students felt. They were able to ask “stupid” questions that would be deemed inappropriate in a clinical setting. The patient described the experience as positive and was encouraged to see so many young scientists working in pain basic science research (personal correspondence between BJK and patient). To the question “On a scale of 1 to 5, how would you evaluate the PURE on-site interaction with a chronic pain patient?” the average student response was 4.5 ± 0.3.

Finally, on-campus at Duquesne, students also had the opportunity to have an informal lunch with a pain psychologist. This clinician described their reasons for being a pain specialist as well as the day-to-day activities involved in their clinical practice. The goal of this session was for students to once again be able to ask “prying” questions about life as a clinician. To the question “On a scale of 1 to 5, how would you rate the PURE on-site interaction with the clinician?” the average student response was 4.5 ± 0.2.

Overall, the patient and clinical interactions were seen as universally positive by students, clinicians, and the on-site patient. In exit surveys students reported significant increases in their ability to “understand what it is like to live with chronic pain” and to “explain pain and/or chronic pain to a patient in lay terms” (Fig. 1).

Pain empathy kit

At Duquesne University, two members of the CPRC, Diane Rhodes and Dr. Lynn Simko, run a semester-long interprofessional course (Pharmacy and Nursing students) dedicated to pain. As part of the course, these researchers developed a pain “empathy kit” that allows people to empathize with chronic pain patients by altering their abilities and sensations to match those of a pain patient. In the PURE program, students were tasked with putting together and using the empathy kit as well as trying to think of new simulations or activities to add to the kit. When using the kit with groups, the session began with a brief overview of pain assessment and etiology, which was then followed by the use of activities to simulate life with chronic pain. The activities were designed to not cause personal harm to users. Examples of activities were walking around the room with popcorn kernels in the bottoms of one’s shoes to simulate peripheral neuropathy or wearing a belt with a golf ball attached at the lower back to simulate chronic low back pain. This kit can easily be assembled and utilized by other programs and courses in order to not only teach and demonstrate physical detriments caused by chronic pain but also to increase empathy and emotional understanding of the daily struggle of pain patients. Improvement of empathy with patients has been shown to improve patient outcomes in the clinic [9]. To the question “On a scale of 1 to 5, how would you evaluate learning and building a pain empathy kit?” the average student response was 4.1 ± 0.3.

Ethics program

All students participated in a 6-week long ethics program that is used by Duquesne’s non-discipline specific Undergraduate Research Program. This ethics program involves groups of students tackling published scientific and medical ethics problems. Students identify the problem, the events that led to the ethical lapse, and methods to avoid similar mistakes in the future. Each group of students is mentored by a faculty member or graduate student during the 6-week process.

Pain conference

Finally, to again expose students to a diversity of pain research topics and to improve their ability to discuss their own research, students participated in two additional activities. After 5 weeks, students spent 2 days at the University of Pittsburgh attending a pain-research conference (http://paincenter.pitt.edu/barriers.htm). Although this conference was a singular event, the incorporation of additional exposure to world-class pain research allowed the students to appreciate the diversity of open questions with the pain research field. The final activity of the summer involved students presenting the results of their research at a 1-day regional scientific conference at Duquesne to a broad audience of researchers. Their research was presented in the form of scientific posters. As a group, the students were given a lesson in poster layout and presentation style and practiced draft versions of their posters prior to the research conference. Students reported significant gains in their ability to “prepare a scientific abstract” and to “prepare a scientific poster” (Fig. 1). Several students have gone on to present their research at additional regional or international conferences after the summer program concluded.

Ethics approval and consent to participate

Study was approved by the Duquesne University Institutional Review Board (protocol #2015-05-10).

Consent for publication

All data from participants was blinded and written consent was given for all participant data presented.

Data availability

Raw data is available for download on the website http://www.duq.edu/about/centers-and-institutes/chronic-pain-research-consortium/publications