How a half million college students could change the future of EM research
The potential is not news to anyone. Two numbers say it all: one-half and more than three. Half the U.S. population comes to an emergency department each year as a patient or a visitor. On average, they are in the ED more than three hours per visit, a good portion of which is spent simply waiting. What researcher wouldn’t dream of access to such a large, captive audience every year? But EPs simply don’t have the time to take advantage of this opportunity.
But what if the work of tapping into this captive audience could be done by someone other than paid clinical emergency personnel? What if there were bright, highly-motivated people available in large numbers who were eager to work with those patients and visitors to facilitate screenings and preventive measures? Better yet, what if these workers could also enter subjects in clinical research or quality improvement projects? Best of all, what if this could all be done at no cost to your department? It may sound too good to be true, but this is exactly what has happened at St. Vincent’s Medical Center in Bridgeport, Conn., where college students aspiring to medical school have been turned into “Research Associates.”
Frank Illuzzi, MD, St. Vincent’s Vice Chair of Emergency Medicine and I, developed the Research Associates (RA) Program in order to take advantage of the powerful, symbiotic potential of waiting patients/visitors and college students eager for first-hand medical experience. Pre-meds can conduct robust research while helping a lot of people get to the primary care screenings and prevention they need, all in a short time frame and at little to no cost. From the program’s inception at Lincoln Medical and Mental Health Center in the South Bronx, over 800 RAs from 95 colleges around the country have served thousands of weekly four-hour shifts in the RA Program, enrolling more than 28,000 subjects in various studies. Since the students volunteer their time, there is no cost to the hospital for their labor. Since 2003, the RA Program at St. Vincent’s has taken on the hospital’s special commitment to cancer care and focused its research efforts on facilitating cancer screenings for ED patients and visitors.
How it works
Over the years, the program has refined its research model. At the beginning of each semester, twenty to fifty RAs attend a two-day orientation to learn how to work with patients and to collect the study data accurately. During a shift (typically one 4-hour shift per week), RAs follow a scripted format to ask the research questions and record the data on a computer at the bedside. In the recent cancer screening study, subjects were told how their cancer screening histories stacked up with American Cancer Society recommendations. They were then given a packet of information about how to obtain needed services.
Since the med students are not directly involved in the patient’s medical care, there is no impact on the patient’s quality of care and thus no need for liability coverage. Nor is there any concern about HIPPA violations. They are simply gathering information and offering a public service at the same time. In fact, by occupying the patient’s attention and showing them that someone is interested in their overall health, RAs convey a message of caring and generally improve the patient’s experience.
Using this model, RAs have enrolled more than 11,000 subjects in studies such as facilitating Pap tests, mammograms, and screening for prostate and colon-rectal cancer, at a rate of about 1000-1500 per semester. From follow-up calls, we are finding that between 20% and 25% of subjects needing a particular screening say they have either had it accomplished or scheduled after their ED visit. Except for a couple of laptops and donuts for orientation, all this is done at no cost to the hospital, which makes administrators very happy.
The RA Program’s tobacco cessation study gives a particularly strong glimpse into the power of this research tool. In 20 weeks, 68 RAs enrolled 3125 subjects in the IRB-approved study. After consent, the RAs asked a detailed smoking history and offered a referral to the Connecticut Quitline, a free telephone-based tobacco cessation service. Among active smokers, 38% accepted a referral. This represented about 40% of all the referrals to the Connecticut Quitline during that time period.
While there are no hard numbers, it is estimated that more than half a million college students each year are trying to get into medical school. This unending stream of pre-meds makes the RA Program sustainable. The studies themselves are ongoing and sustainable as well; when an RA completes a current study, they simply move into service based on the previous successful research. For example, after the Dental Check-Up study going on now, patients and visitors in the St. Vincent’s ED still get asked about tobacco cessation and the other cancer screenings.
Going National with NARAP
The RA Program in Connecticut is expanding the model to other institutions through the recently-formed National Alliance of Research Associate Programs (NARAP). The plan is for twelve or more institutions, half academic centers and half community hospitals around the country, to join together for a validation of the tobacco cessation study piloted at St. Vincent’s. During 30 weeks of the academic semesters in 2012, this consortium will enroll more than 50,000 subjects in the research, potentially making it one of the largest clinical studies ever done over such a short time frame.
To accomplish this, NARAP helps member institutions develop their own RA programs, starting with the training of Chief RAs. These are the leaders who do the work of recruiting RAs from local colleges, scheduling, monitoring RA performance and database management. They take first call 24/7 for any issues line RAs have on a shift. Each NARAP hospital can send four post-bacs – college graduates taking a year or more between college and medical school – to St. Vincent’s for the summer to train as Chief RAs. Under the physician supervision of each RA Program, these Chiefs volunteer about twenty hours per week doing the “grunt work” to keep the program at their institution running smoothly.
Under the NARAP model, RAs are paired on a shift, one conducting the tobacco cessation study while the other is free to collect data for whatever quality improvement project their particular hospital wants them to do. It doesn’t cost the NARAP member institutions any money to join this national initiative. All they are asked to do is support the grant applications for NARAP to cover administrative costs.
Emergency departments in Hartford and New London, Conn. are currently leading their new RA Programs through NARAP in a trial of the multi-center format preceding the national study to take place in 2012. The Creighton University Department of Emergency Medicine has also signed on to join the Connecticut hospitals as NARAP member institutions for the 2012 study.
As a number of hospitals finalize NARAP membership, the research organization is still looking for community hospitals and academic centers who might want an RA Program in their institution and join the multi-center tobacco cessation study.