Mentors in Medicine Program
Mentors in Medicine-International
Division of Medical Education
Washington University School of Medicine
Application
Resident Applicant’s Name:
Faculty Primary Mentor Information
Name and title: Telephone number:
Department/Division: E-mail address:
If you have a secondary mentor, please complete this section:
Faculty Secondary Mentor Information
Name and title: Telephone number:
Department/Division: E-mail address:
______
You may apply to MiM or MiM-I. Please refer to the website http://meded.dom.wustl.edu/education-programs.html for a detailed description of the programs and commitments.
I am applying for the following program(s).
____ Mentors in Medicine
____ Mentors in Medicine-International
______
Using the instructions below complete the project outline in single-spaced type with one-inch margins and 12-point font. There is no page limit. Most applications are 3-5 pages of text excluding bibliography. The following headings should be used:
Project Title:
Research Question, Hypothesis or Goal:
Give a one to two sentence description of the question to be addressed.
Although there are exceptions, the hypothesis should be testable.
Background and Statement of Problem:
State why the problem is important and outline the evidence that forms the basis for the hypothesis and/or goal stated above. Include appropriate references.
Intervention:
Describe your experimental design. Include methodology for using controls. Provide details regarding your specific (the resident’s) role in implementing the proposal.
Outcome Measurement:
Define the primary and secondary outcomes and describe how and when each will be measured.
Patients and Other Materials (if applicable):
Describe the available patient population. To demonstrate feasibility, include the volume of patients, procedures per month/year, or availability of existing data.
Data Analysis:
State the main statistical tests that you propose to use to evaluate the primary and secondary outcomes. You may wish to confer with a biostatistician or the Research Design & Biostatistics Group (RDBG).
Sample Size Estimation:
State the clinically meaningful change in the primary variable that you want to detect with your study. Calculate how many units (patients, wards, hospitals, animals, etc.) you will need in the study to measure such a change. It is recommended that you use a two-sided alpha=0.05 and beta=0.20.
Project Role:
Please state your specific role(s) on this project; be as specific and complete as possible.
MIM-I ONLY:
Please identify a dyad that will be working with you on your project in the country you chose.
Budget Estimate and Budget Justification:
Give an estimated budget for data collection, statistical support, patient participation and other supplies. Travel to a scientific meeting for the purpose of presenting results may be budgeted. Maximum budget allowed for the 2015-2016 academic year will be $4,500. Please be specific; all budget items must be justified (please see attached policies). For specific budget details, please see attached Budget Example and Guidelines.
References:
List any pertinent references to support the background and design of your proposal.
Mentor Letter:
Provide a letter from each of your mentors indicating that he/she/they has/have read and support(s) your proposal. Include any additional support that the mentor will provide-such as data, supplies, funding, and/or personnel (e.g. research assistant, laboratory technician, or biostatistical consultation).
CV of applicant:
Please attach a current copy of your CV.
Publications:
Please provide a complete list of publications you have submitted during your residency.
______
If you have any questions or need assistance in preparation, contact Sara John, the Mentors in Medicine Coordinator, at or 314-362-8065. Please submit your completed application and any additional information/attachments by e-mail to . You will receive a confirmation email that your application was received.
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