In the United States, there is growing concern over the shortage of physician researchers.1,2 Participation in research during residency may help address this shortage by increasing interest in a research career. At the individual level, resident scholarly activity productivity (RSAP) is associated with choosing an academic career.3–6 At the programmatic level, residency programs with higher levels of RSAP yield residents who are more likely to pursue academic careers.7 Even for those residents with no interest in a research career, participation in research is valuable in that it may improve the patient care they provide by increasing their comfort with evidence-based medicine8 and enhancing their analytical and critical thinking skills.2,9
The Accreditation Council for Graduate Medical Education (ACGME) requires that residency programs provide curricula that advance residents’ knowledge of the basic principles of research, ensure resident participation in scholarly activity, and allocate resources to facilitate this participation.10 The ACGME has recently added required reporting of resident scholarly activity, including publications and regional, national, or international presentations.11 Although steadfast in its requirement for scholarship in residency, the ACGME has never given specific recommendations about how this should be achieved. As a result, individual programs have developed diverse curricula to meet the requirement, resulting in variable productivity and satisfaction.12–20 However, multiple barriers to successful resident scholarly activity have been described, including lack of time, mentorship, and resources,20 along with variability in resident attitudes toward scholarly activity.21
A better understanding of interventions that promote RSAP may help program directors meet ACGME scholarly project requirements and foster the development of a productive workforce in academic medicine. Few studies have attempted to determine which program qualities lead to increased scholarly productivity.20,22,23 A prior systematic review published in 2003 focused on describing resident research curricula but did not address RSAP.9 In this systematic review, we seek to answer the following question: Among residency training programs in the United States and Canada, what interventions at the programmatic level are effective in increasing RSAP, as measured by participation in scholarly activity, publications, or presentations? Knowledge gained through this research can provide program directors across specialties with best practices to increase RSAP within their own programs.
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines,24 we systematically reviewed articles that described outcomes of interventions designed to increase RSAP. A review protocol is available from the authors upon request.
A librarian (E.M.S.) conducted all literature searches in consultation with the research team. Electronic searches of the PubMed and MEDLINE (peer reviewed), Cochrane Library of Systematic Reviews, CINAHL, PsycINFO, and ERIC databases were conducted from database inception through October 9–10, 2013. Search terms included the domains of residency, graduate medical education, research, research training, and scholarly activity. Keyword and medical subject headings (MeSH) search strategies were used for PubMed. The MeSH search strategy included the terms “Education, Medical, Graduate,” “Internship and Residency,” “Medicine/education,” and “Research.” A keyword search was conducted in the Cochrane Library database. The remaining databases were searched using controlled vocabularies. For full search strategies, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A338.
We performed a hand search of the bibliographies of included articles. We did not search conference proceedings.
Study selection and definitions
We limited articles to studies on residency programs in the United States or Canada (because of similarities in training requirements) and published in English. We included randomized control studies, case–control studies, cohort studies, survey studies, and analyses of programs that evaluated factors or interventions to increase RSAP in any medical specialty. No date limits were applied. Exclusion criteria were lack of relevant outcome, lack of control group, editorials and commentaries, and articles focused exclusively on fellowships or combined MD/PhD programs.
Our primary outcome was RSAP, defined as research project participation, presentations, or publications by residents. Our secondary outcomes included attainment of grant funding (because reporting of grant funding is not required in the Next Accreditation System11) and fellowship or faculty positions.
Two standardized data collection forms were developed, pilot tested, and approved by our research group. The first form was used to select potentially applicable articles based on pertinent titles and abstracts. It was piloted and finalized by two reviewers (S.T.L. and M.D.S.). The second form served as our main data extraction tool, and it documented reasons for article inclusion or exclusion after full-text review. All reviewers (S.T.L., M.D.S., C.T., E.A., M.N.) pilot tested the data collection form on two articles each (n = 10). The form was then revised and used to collect data on the articles selected for full-text review.
After the initial search, one reviewer (E.M.S.) screened all records to exclude editorials and commentaries. Two reviewers (S.T.L. and M.D.S.) screened titles and abstracts of all remaining records to identify articles that appeared relevant for full-text review and randomly distributed them equally among all reviewers (S.T.L., M.D.S., C.T., E.A., M.N.). Two reviewers independently reviewed each article, extracted data, and determined whether the article met study inclusion criteria. We resolved discordance by discussion and consensus.
Data elements recorded for fully reviewed articles included citation information, study design, program specialty, study population (residents, program directors, or research directors), sample size, intervention or type of observation, and outcomes. Risk of bias was assessed among the articles that reported statistics using the Medical Education Research Study Quality Instrument (MERSQI), a validated scoring tool for medical education research.25 A maximum possible score of 15 (indicating high quality) on the MERSQI was used because one score component (regarding validity of an evaluation instrument) was not applicable to the articles in our review.
Because of expected heterogeneity in the reporting of primary outcomes of RSAP, we did not plan or perform a meta-analysis. For articles that reported statistics, we categorized results by type of RSAP outcome, and we summarized the results separately for surgical and medical specialties because of differences in training program structures. Because we were concerned that our results might have been influenced by self-selection of residents interested in an academic career into training programs with better infrastructure for scholarly activity, we evaluated studies that controlled for potential confounding variables (e.g., resident gender, prior research experience, or level of training) separately.26 We discussed and, by group consensus, summarized overall trends in associations between interventions and RSAP outcomes.
Characteristics of all included studies
We identified and screened the titles of 6,248 records after removal of duplicates (see Figure 1). Of the 848 abstracts screened for inclusion, 192 were chosen for full-text review. Of the 80 articles that underwent data abstraction, 26 studies13,16,27–50 described outcomes without a comparison group (for details of these 26 studies, see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A339). Fifty-four studies4,8,12,14,15,17–19,22,23,51–94 describing outcomes with comparison groups were included in the final analysis.
Thirteen specialties were represented: 9 medical specialties (69%) and 4 surgical specialties (31%). Associations between studied interventions and RSAP outcomes reported in the 54 included studies are summarized in Appendix 1, categorized by medical (n = 38; 70%) or surgical (n = 16; 30%) specialty. The 54 studies evaluated outcomes using a historical cohort design (n = 36; 67%), case–control design (n = 2; 4%), or cross-sectional survey of residents or program/research directors (n = 16; 30%). Interventions included a requirement for participation in scholarly activity, protected research time (of varying duration), a research curriculum, a dedicated research day, a research track, and a research director. Among medical specialty studies, 15 of the articles17–19,23,51,53,56,60,64,65,71,75,79,92,93 reported trends toward improvement in outcomes with the studied interventions but did not use or report statistical analysis; the surgical specialty literature included 4 such articles.66,72,76,83 To focus on literature of higher quality, in the remainder of our review, we summarize results from the 35 articles that reported statistical analysis.
Characteristics of articles reporting statistical analysis
Table 1 summarizes the effect of studied interventions on RSAP outcomes, restricted to the 35 articles that reported statistical analysis. Appendixes 2 and 3 report detailed findings of these articles for medical specialties (n = 23; 66%) and surgical specialties (n = 12; 34%), respectively. Fifteen of these 35 publications involved data from multiple programs, obtained either through surveys of residents or program/research directors (n = 14) or, in 1 article,90 through searching publicly available information. The sample size for the 14 studies with a survey design ranged from 60 to 1,474 participants, with a median response rate of 63% (range 24%–92%).22,52,55,57,59,67,68,70,74,85–87,89,94 The sample size for the 2 case–control studies14,88 and the 19 cohort studies4,8,12,15,54,58,61–63,69,73,77,78,80–82,84,90,91 varied from 24 to 626 residents. Study quality scores, using the modified MERSQI, ranged from 8 to 13 across the 35 articles.
Interventions associated with participation
All 5 publications (4 medical and 1 surgical) that evaluated resident participation in scholarly activity as an outcome reported increased participation as a result of the intervention(s) studied. Multiple studies bundled interventions, including protected research time, a research day, research curricula, a research track, and/or a research requirement.8,22,58,77,85
Interventions associated with presentations
Results of the 10 studies8,15,57,61,69,80,82,87,89,94 addressing presentation of scholarly work by residents were mixed in both medical (5/8) and surgical (1/2) specialties. In the medical specialties, a research director (3/3)* resulted in increased regional and national presentations.61,69,94 In 2 of these studies,69,94 a research director was combined with a research curriculum and protected time. Of the remaining 5 medical specialty studies without a research director (but using a combination of protected time, research curriculum, research track, and/or research requirement), only 2 showed a positive effect on presentations.82,89 In the surgical specialties, 1 study found a positive association between a research requirement and presentations.80 A multicenter study of orthopedic residents found no association between presentations and programs with a research director, research curriculum, and/or protected time.57
Interventions associated with publications
Most studies in both the medical (n = 17) and surgical (n = 8) specialties studied the effect of multiple interventions on publications.
In the medical specialties, a research track (4/4)67,70,82,86 and a research director (3/4)61,69,88 increased publications. Two studies combined a research director with a research curriculum and protected time.69,88 The majority of studies found that providing protected research time (7/12),22,67,69,78,82,86,88 a research curriculum (9/11),14,22,52,69,73,78,82,86,88 and/or a research day (5/6)12,22,73,78,82 was associated with increased publications. Protected time most often ranged from 1 to 3 months8,15,52,69,82,87,88; however, 1 program allowed up to 6 months,78 and in 2 multicenter studies the majority of psychiatry residents86 or radiation oncology residents67 had ≥ 6 months of dedicated research time. In the medical specialties, an increase in publications associated with protected time was always found in association with another intervention: a research curriculum (n = 6), a research day (n = 3), a research track (n = 3), a research director (n = 2), and/or faculty support (n = 1). Only 3 studies found a positive effect on publications from a single intervention: a research day,12 a research track,70 or a research director.61
In the surgical specialties, protected research time (6/7)4,57,59,68,90,91—either as a single intervention (3/4)57,68,90 or in combination with a research requirement (1/1)59 or track (2/2)4,91—was the most common intervention associated with increased publications. Three articles reported an average of 1 year of protected research time,4,59,91 while others reported mean protected research time of 4 to 5 months,57,68 and 1 multicenter study reported a range of 0 to 12 months.90 The duration of protected research time was significantly associated with the quantity of resident publications in the majority of these studies.57,59,68,90 A research director did not improve publication rates.57
Interventions associated with grants, fellowship positions, and faculty positions
Acquisition of research grants was the least commonly studied outcome, examined in just 3 medical and 2 surgical studies. In 1 multicenter study from radiology,70 participation in an introduction to research program was associated with attainment of intramural research funding. Similarly, residents from multiple radiation oncology programs who participated in a specialized research track were more likely than nonparticipants to obtain peer-reviewed grants based on work initiated during residency.67 In contrast, a small pediatric training program did not find a significant increase in grant funding after implementation of a research curriculum, protected research time, and a research day.15
In the surgical specialties, 1 multicenter study found that orthopedic residents who had at least one month of protected time for research were more likely to obtain grant funding during training than those with less time. Having a research director or a research curriculum did not have an impact on grant funding.57 Another study from a single general surgery training program found that the number of publications as a resident was associated with faculty grant support.81
Fellowship and faculty positions.
One study (1/4) in the medical specialties showed a positive association between an intervention and either fellowship or academic faculty positions: A large multi-institutional study of radiology residents demonstrated that participants in a research track were more likely than nonparticipants to pursue faculty positions.70 In 5 studies (5/6) in the surgical specialties, protected research time during residency was associated with obtaining a fellowship and/or academic faculty position after completion of training.54,59,63,68,90
Studies that addressed potential confounding variables
Eight articles employed a matched case–control design,14 multivariate logistic regression analysis,12,22,55,67,74,94 or Poisson regression analysis68 to account for potential confounding variables. Only 1 of these articles was in a surgical specialty.68
Three articles evaluated the outcome of participation in scholarly activity22,55 or residency review committee (RRC) citation for lack thereof74 while controlling for confounding variables. Dedicated research time, a research day, program director involvement, and resident recognition for scholarship were associated with resident participation in research in family medicine programs.22 The presence of funding specifically for resident scholarly activity was the only factor protective against RRC citation for lack of such activity in internal medicine residency programs.74 In contrast, only mentorship outside of the department was significantly associated with fewer completed projects among physical medicine and rehabilitation training programs.55
Six articles controlled for confounding variables when examining the outcome of publications.12,14,22,67,68,94 One of these articles also evaluated grant funding,67 and another also evaluated presentations.94 Publications by program directors and by multiple other faculty (six or more faculty publications within two years) were associated with resident publications among family medicine programs.22 After adjustment for gender and prior publications, an association between participation in a research day and resident publications was demonstrated in a pediatric training program.12 In another study, conditional logistic regression confirmed that pediatric residents with a research requirement and research curriculum were significantly more likely than those without a research requirement to publish both during and after residency.14 Accounting for prior publications and postgraduate year, the number of months of protected time for research had a significant impact on the number of manuscripts submitted across urology residency programs.68 After adjustment for gender and prior publications, radiation oncology residents who participated in a specialized research pathway were more likely than nonparticipants to be successful in obtaining grant funding.67 While the quantity of protected time for research was not a significant predictor of grant funding in that study, it was the sole factor associated with resident first-author publications in multivariate analysis. In contrast, no interventions were found to predict resident publications in a multicenter study of emergency medicine residency programs, yet departmental financial support and protected time were associated with presentations.94
We found that interventions to increase resident participation in scholarly activity were uniformly positive in their effects. Scholarly activity participation in residency is the minimum ACGME requirement. As resident participation in scholarly activity, without necessarily having a tangible product, is relatively easy to achieve, it is not surprising that multiple different interventions resulted in increased participation. For example, mandating participation of residents in scholarly activity was as effective in increasing participation as more resource-intensive approaches such as protected research time, a research curriculum, and having a research track or research director.
Increasing tangible products of scholarship, such as presentations or publications, was more difficult to achieve, and the results were mixed. In many studies, interventions were bundled, so it was difficult to determine the relative importance of a single intervention. For example, having a research track or research director was associated with increased presentations and publications, but each of these interventions was often paired with protected research time and a research curriculum. Solely giving residents protected research time or a research curriculum was not consistently sufficient to increase presentations and publications, particularly in the medical specialties. Programs may need to provide increased structure and rigor through multiple pathways. In the medical specialties, a research director was associated with increased presentations and publications, emphasizing the importance of having an identified champion of scholarship within a residency program. In surgical specialties, program directors who wish to increase resident publications are likely to achieve success by providing increased protected time for research. Extensive time for research may not be feasible to offer in programs in all specialties without lengthening the time of training, however.
The results from the studies that accounted for potential confounders support the key concept that overall program research culture influences RSAP. When study authors adjusted for prior research experience or publication (which could serve as a proxy for interest in an academic career), all studied interventions (a research day, specialized research track, or protected time) were associated with RSAP.12,67,68 Mentorship, particularly within the department specialty, also played an important role in RSAP.22,55 Finally, funding for resident scholarly activity was associated with program compliance with ACGME guidelines.74
Our review illustrates the diversity of approaches to support RSAP at the programmatic level across graduate medical education specialties, reinforcing the need for clarity in the definition of resident scholarship and expected outcomes. Programs are now required to provide evidence of resident products of scholarly activity through the Next Accreditation System,11 yet how the ACGME will interpret the reported outcomes remains unclear. In response, some specialties such as orthopedic surgery have at the RRC level defined the expected outcomes of participation in sponsored research, manuscript preparation/publication, participation in a structured literature review, or presentations.95 Simultaneously, the ACGME’s 10-year self-study requires programs to define their own aims—which could apply to scholarly activity—“as a way to differentiate programs,” and is expected to “ultimately evaluate program effectiveness in meeting these aims.”96 Through a recent editorial, Simpson and colleagues97 actively solicited the opinions of medical educators about whether all graduating residents should produce scholarship that adds to the body of knowledge and whether requirements for resident scholarship should be redefined. The published findings were mixed, with some respondents advocating a universal requirement for scholarship, while others disagreed, citing logistical barriers and resource challenges.98
We propose that individual residency programs should clearly define their own goals for RSAP, meeting or exceeding the minimum requirement outlined under the RRC for their specialty. While some programs may have resources, infrastructure, and the desire to support scholarly activity during residency to train future physician scientists and academic leaders, others may excel in training future community practitioners. The latter types of programs should focus on ensuring that their graduates understand the rigors of a scholarly approach to clinical questions, appraisal of the literature, quality improvement, and community health and place less emphasis on publications and presentations as outcomes. A third type of residency program may seek to prepare graduates with career interests in either area. Each of these program categories will vary in their RSAP outcomes at the programmatic level, as well as in their choice of interventions to achieve their program goals. Expected RSAP outcomes by program type should be incorporated quantitatively into accreditation review, aligning with the aforementioned goal of the ACGME’s 10-year self-study.96 Further, programs should work with their residents to tailor scholarship opportunities to the residents’ individual career goals within the program’s overall expectations of scholarship.
We support future efforts of programs and the ACGME to define expectations for resident scholarly activity at the program and individual resident levels using a universal language with clearly outlined outcomes in order to reach the goal of developing a cadre of physicians with differing skill sets yet encompassing all domains of scholarship across the profession.99 With expectations defined, programs may then more carefully choose, and rigorously study, interventions that align with their aims to support RSAP.
Our review has several limitations. Although our inclusion criteria were broad to maximize our assessment of the available literature on scholarly activity during residency, we did not search conference proceedings, and we limited our review to studies performed in the United States and Canada and published in English. Publication bias may have led to inclusion of studies with more positive outcomes. Not all studies may have accounted for the possibility that residents interested in scholarship self-selected into training programs that supported scholarly activity. Because of the heterogeneity of the studies, it was not possible to combine results quantitatively in a meta-analysis. The cost of the interventions is an important consideration for programs100 but was not well described in the included studies. Finally, multiple barriers to RSAP encountered by residents (e.g., motivation, navigating institutional review boards, time to complete projects, support for study design and analysis), which are beyond the scope of this review, must be considered as programs develop goals and support for resident scholarship.
Interventions such as protected time, research training, a research director, or a specialized research track generally resulted in increased resident participation in scholarly activity in U.S. and Canadian training programs across medical and surgical specialties, but had mixed effects on presentations or publications by residents. Our findings highlight the need for a clear definition of resident scholarly activity success, aligned specifically to individual program and resident goals.
Acknowledgments: The authors wish to thank Kendra Sikes, E.I.T., and the Kornhauser Health Sciences Library interlibrary loan staff for their assistance.
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