Medical trainees are uniquely positioned as both learners and members of the medical workforce and can provide frontline insights on important issues in academic medicine. Accordingly, understanding the needs and perspectives of trainees and engaging them in scholarly medical education discussions are important. Moreover, trainee involvement in educational scholarship fosters scholarly habits and mentor relationships while also encouraging the development of a personal learning network that can promote a framework for a career in academic medicine.1,2 Finally, scholarly publications are critical for trainees seeking competitive residency, fellowship, or academic faculty positions or promotion.3–5
To engage trainees in scholarship, many medical schools and residency programs have created scholarly programs or tracks within their curricula, including tracks in “medical education.”6,7 Although there is emerging evidence that such tracks increase trainees’ interest in research generally,8 the impact of medical education tracks on trainee-driven medical education scholarship has not been described. To better analyze these downstream effects, attention must first be paid to cataloguing the current state of trainee involvement in education scholarship, which to our knowledge has not been described in the literature.
One metric for assessing trainee scholarship is analyzing trainee authorship of peer-reviewed publications. Studies based in New Zealand, Denmark, and Germany have described an increase in student involvement in medical publications over time.9–11 These studies performed citation-indexed searches to identify trainee-authored publications. Interestingly, one study noted that fewer than 3% of trainee-coauthored studies mention the trainee’s academic status, highlighting the challenge of identifying student- and resident-authored publications.12 The Association of American Medical Colleges Graduation Questionnaire has tracked the percentage of medical students reporting “authorship (sole or joint) of a research paper submitted for publication,” which increased from 32.9% in 2002 to 46.5% in 2016.13,14 Although these data suggest a general increase in student authorship, they are self-reported by medical students, do not account for residents, do not necessarily reflect published papers, and are not specific to publications in medical education. A recent and novel study analyzed trainee authorship in a medical education journal: Burk-Rafel and colleagues found that medical students and residents made up just 2.8% and 4.9% of authors, respectively, in Academic Medicine in 2016, suggesting modest trainee engagement in medical education scholarship.15 However, that analysis was limited to a small sample from a single year and journal.
The objective of this study was to quantify medical student and resident authorship of medical education publications over a 15-year period, including trends in prevalence, author position (first, middle, or last), and publication type. By understanding trends in trainee authorship, we can better investigate the impact of interventions to increase trainees’ scholarly activity, such as medical school and residency scholarship tracks, and can begin to measure the impact of these trainee-authored publications.
Journals whose primary publishing focus is medical education were identified by one author, an informationist (W.A.T.), who combined and deduplicated all journal titles from the “Education, Health and Science” category in Thomson Reuters Journal Citation Reports 2016 with all journal titles in the National Library of Medicine Catalog indexed with the major MeSH term “Education, Medical” at the journal level. To ensure that no major journals focused on medical education were excluded, the informationist searched the Scopus database for medical education-related articles (see Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A603) and grouped the results by source journal; no additional journals with a distinct medical education focus were identified. It should be noted that general and specialty medical journals (e.g., JAMA, Annals of Internal Medicine) routinely publish medical education articles. We excluded such journals from consideration because most of their publications are unrelated to medical education and our analysis was conducted at the journal level.
After deduplication, 91 unique journal titles remained. Journals were reviewed by two authors (W.A.T., J.B.R.) and excluded if their scope was irrelevant to general medical education or if they were non-English language, inconsistently included in PubMed, not indexed by Medline, or no longer published. For each of the 16 remaining journals, we checked 3 citations from 2015 for inclusion of author role information in the full-text PDF-version article and in the PubMed record field (see Supplemental Digital Appendix 2, available at http://links.lww.com/ACADMED/A603). To permit analysis of trainee authorship data, journals need to identify authors’ professional standing and credentials. Seven journals included author role information identifying trainees in some full-text articles but did so inconsistently and did not include this information in the downloadable PubMed record. Only Academic Medicine consistently provided detailed author roles in the downloadable Medline format, permitting a complete retrospective analysis (Figure 1).
We downloaded all citation records from Academic Medicine for the study period (January 1, 2002 to December 31, 2016) retrospectively in early 2017 via Ovid Journals Platform and imported the records into an Excel file (Microsoft, Redmond, Washington). Records included basic article information (year, issue, page, title), author affiliations (author names, roles, and organizations), and the article abstract. We excluded records that were duplicates, had incomplete author affiliation information, were nonscholarly articles (e.g., foreword, preface, appendix, editor note, correction), or were published ahead of print.
For each remaining citation record, we counted the total number of authors. Using native Excel search capabilities, the author affiliation field was then interrogated to flag likely medical student and resident authors by searching for terms such as “medical student,” “resident,” and “house officer.” We did not include undergraduates, PhD students, and fellows as medical trainees in this work. When multiple roles were indicated in the affiliation field, the role at the time the work was completed was used for analysis. For each identified trainee author, we noted the authorship position (first, middle, or last). Authors of single-author publications were considered first authors; middle authorship was only applicable for publications with three or more authors. Two authors (B.W.M., M.G.) subsequently manually screened the records for accuracy of trainee status designation and corrected inaccurate classifications.
Publication type identification
Each citation included a “database” field labeling the record as 1 of 488 subtypes. By examining article abstracts and content, and reviewing the Academic Medicine instructions for authors,16 we categorized these subtypes into six distinct publication types:
- Research (data-driven structured abstracts including research reports, innovation reports, and review articles);
- Article (unstructured abstracts on wide-ranging topics);
- Commentary (invited perspective pieces);
- Perspective (unsolicited perspective pieces);
- Humanities (Medicine and the Arts, Teaching and Learning Moments, and Gold Foundation Humanism Essays); and
- Letter to the Editor.
Data analysis and statistics
We analyzed the prevalence of trainee authors for the entire study period, delineating by publication type and author type. Author position—with first or last position taken to indicate a leadership role in the publication compared with middle authorship17—was also noted. Subsequently, we analyzed temporal trends in overall trainee authorship using three-year bins, which were selected to increase statistical power while maintaining sufficient granularity to compare time periods. Sensitivity analysis was performed to ensure that findings were not sensitive to changes in binning (e.g., analysis by publication year) or article type inclusion (e.g., excluding Letters to the Editor and Humanities publications). We tested trainee authorship trends using the Cochran–Armitage chi-square test, with the null hypothesis of no linear increase, using RStudio statistical software, version 1.0.153 (Boston, Massachusetts). Mean differences were tested using Student t test. The alpha level was set at 0.005 based on the Bonferroni correction for multiple comparisons.
Our initial download of Academic Medicine citations yielded 6,280 individual publication records. Of these, 1,645 did not meet inclusion criteria and were excluded, leaving 4,635 records for analysis (Figure 1).
Table 1 summarizes the prevalence of medical student and resident authors among the analyzed records. In total, we analyzed 16,068 author positions, of which 502 (3.1%) were medical students and 464 (2.9%) were residents. Of the 4,635 publications analyzed, 367 (7.9%) included one or more medical student authors and 355 (7.7%) included one or more resident authors. Medical students and residents were in the first or last author position on 276 (6.0%) and 248 (5.4%) of all publications, respectively. Some papers included both student and resident authors, yielding a total of 673 publications (14.5%) involving either medical students or residents as authors in any author position.
Research publications were the most numerous type of trainee-authored publication, with 117 student- and 155 resident-authored publications. Research publications also involved the most overall trainee authors, including 170 student and 214 resident author positions, although these trainees represented just 2.2% and 2.8%, respectively, of all research publication authors. Humanities publications—although a less common publication type—produced the highest rate of trainee authorship, with 22.9% (110/480) and 10.6% (51/480) of publications including student or resident authors, respectively. Letters to the Editor garnered the second highest rate of trainee authorship, with 8.6% (57/663) and 8.4% (56/663) of letters including student or resident authors, respectively. Articles and Commentaries had the lowest rates of trainee-authored publication and had the smallest proportions of trainee authors of all publication types.
Trainees were in the first- or last-author position on 75.2% (276/367) of student-authored publications and 69.9% (248/355) of resident-authored publications. Almost all Commentaries, Letters to the Editor, and Humanities publications involving a medical student or resident included a trainee in the first- or last-author position. In contrast, only about half of trainee-authored Research publications included a trainee in the first- or last-author position.
Over the 15-year study period, the percentage of publications of any type with either medical student or resident authors increased from 9.4% (58/620) in years 2002–2004 to 18.8% (225/1,199) in years 2014–2016 (Cochran–Armitage test of trend P < .001) (Figure 2). Over the same period, trainee first-authored publications increased from 5.5% (34/620) to 12.8% (153/1,199) (P < .001 for trend) and middle-authored publications increased from 3.2% (20/620) to 8.3% (99/1,199) (P < .001 for trend), while trainee last authorship did not significantly change (1.9% [12/620] to 1.5% [18/1,199], P = .20 for trend).
Considering medical student and resident authors separately, similar trends were observed: From 2002–2004 to 2014–2016, the prevalence of student-authored publications increased from 4.4% (27/620) to 10.3% (124/1,199) (P < .001 for trend), while resident-authored publications increased from 5.2% (32/620) to 9.8% (118/1,199) (P < .001 for trend).
The observed temporal increase in the number of trainee-authored publications was associated with a coincident increase in the number of trainee authors: The total number of medical student authors increased from 33 to 171 (a nearly 420% increase), while the number of resident authors increased from 40 to 159 (a nearly 300% increase) from 2002–2004 to 2014–2016 (Figure 3A). As a proportion of all authors, medical students increased from 1.8% (33/1,853) to 3.7% (171/4,632) (P < .001 for trend) and residents increased from 2.2% (40/1,853) to 3.4% (159/4,632) (P < .001 for trend) (Figure 3B). Sensitivity analysis using alternative binning or excluding certain publication types resulted in similar findings.
To assess whether the observed temporal increase in trainee middle authorship rate was associated with a coincident increase in authors per publication, we calculated the number of authors per publication, which increased about 30% over the study period, from 3.0 authors per publication (SD 2.2; 95% confidence interval [CI]: 2.8–3.2) in 2002–2004 to 3.9 authors per publication (SD 3.0; 95% CI: 3.7–4.0) in 2014–2016 (P < .001) (Figure 4).
The purpose of this study was to understand trends in medical student and resident authorship of medical education publications. Across 15 years of Academic Medicine publications, medical students and residents authored publications at similar rates (around 8% each), suggesting that scholarship in medical school may be sustained in residency. We also found that research articles were the most numerous type of publication to involve trainees. Original research offers trainees an opportunity to gain an in-depth understanding of the scientific process, cultivates scientific curiosity, and fosters positive attitudes toward scholarship.18,19 In contrast, trainee-authored articles and commentaries were a small proportion of publications in Academic Medicine; measures to encourage trainee submissions to these publication categories may be an area of opportunity for stimulating additional trainee scholarship.
Medical humanities publications stood out from other publication types with the highest rate of trainee authorship, suggesting that trainees provide an important and unique viewpoint in the medical humanities. Identified by many educators as a critical aspect of modern medical education,20 the medical humanities foster trainees’ humanism, which is essential for developing medical professionalism.21,22 Likewise, the medical humanities can promote trainees’ sense of meaning in their work23 and combat the moral distress of training,24 thus improving wellness. A recent review identified numerous humanities-related curricular innovations among medical schools,25 perhaps in part explaining the high rate of publication we observed in this domain among medical students. The strong trainee representation among authored humanities publications highlights the importance of socializing trainees to define scholarship broadly, and not merely as research publications. Academic Medicine has embraced this trend, with editorials that acknowledge the importance of health humanities scholarship,26 articles that recognize the unique contributions of learners in this area,15 and a Humanities in Medicine blog section.27 Notably, at Academic Medicine, humanities publications forgo external peer review and are instead peer reviewed by journal editors and staff, with the best submissions selected; it is unclear whether this modified peer review process is associated with the high trainee publication rate.
Trainee authorship across all publication types in Academic Medicine doubled over the 15-year study period. This study was not designed to determine the etiology of this increase, but trainee-, institutional-, and journal-level factors are possible contributors. The number of students and residents relative to academic physicians has increased in recent years with the growth of training programs, increasing the pool of trainee authors for medical education publications. Similarly, medical school admissions and residency selection processes have become more competitive over time, and trainees increasingly have prior research experience or take time during training to focus on research, factors that may make them well suited to publishing their work.28–32
Institutions, too, have evolved: Medical schools and residency programs are providing resources and mentorship for scholarship through scholarly medical education tracks.6,7 Future analyses are needed to determine whether there is a correlation between such medical education tracks and trainee authorship. Finally, journal-level changes may also partly explain the increased trainee-authored publications. For example, Academic Medicine has introduced Innovation Reports for early-stage innovations not yet robust enough for full-scale research that might be apt for trainee investigators,33 generated calls for submissions specifically from medical students and residents,34,35 and published unique article types like the Gold Humanism in Medicine Essays, which feature only trainee work.
Trainee authorship trends differed by author position. First and last authors typically have the highest level of contribution among all authors on scientific publications,17 with first authorship being highly valued for tenure and promotion and last authorship typically indicating project mentorship.36,37 We found that the increased trainee authorship was largely driven by increased first authorship, with some contribution of increased middle authorship and no contribution of last authorship. This suggests that trainees may be leading scholarly efforts, with the backing and mentorship of more senior academicians. As expected, trainees constitute a small proportion of last authors, as they typically are not yet serving as scholarly mentors.
The number of authors per publication increased over the study period, a trend that has been noted among all PubMed publications.38 Although this trend may in part explain the observed increased trainee middle authorship, the number of first-author positions is unaffected by increased numbers of authors per publication. Thus, the increased first authorship we observed—which appears to be the primary driver of increased trainee authorship rates—represents a true increase in trainee authorship. Moreover, we found that the number of medical student and resident authors increased significantly as a fraction of all authors over the study period—outpacing any growth in total authors or publications.
Creating the next generation of academic scholars requires encouraging early scholarly participation and positive attitudes toward research among trainees.39 Engagement with research during medical school and residency is associated with future career research and involvement in academic medicine.19,40,41 Training programs can foster general research interest and skills among trainees by introducing institutional initiatives (e.g., formal research curricula, mentorship, and logistical support)42,43 and by supporting trainees’ intrinsic motivations to conduct research by granting them autonomy and making clear the connections between research and clinical practice.44 Similar approaches appear to be effective at specifically promoting medical education research among medical students and residents.45,46
Outcomes of any initiatives to support student and resident scholarship should be studied to measure effectiveness. Tracking trends in trainee authorship across varied medical education journals would provide a surrogate measure of trainee scholarly engagement and the pipeline of academic scholars. Unfortunately, of the 16 general medical education journals meeting our inclusion criteria, only Academic Medicine consistently included the roles of medical students and residents in downloadable citations, calling into question whether most medical education journals consider it important to identify trainee authors. We would argue that journal inclusion of author role and rank has benefits for both trainees and the scholarly community. At the very least, trainee role notation on the authorship byline enhances trainee recognition, providing positive reinforcement that is critical for continued scholarly activity.47 We encourage all medical education journals to require authors to indicate their role or trainee status at the time the submitted work was completed; journals should then include these author roles in their published articles and consistently report these data in the PubMed affiliation field. By collecting and publishing this information, journals acknowledge and promote the hard work of trainees within the field of medical education, encouraging continued scholarly engagement among the next generation of researchers.
Although this study provides insight into the number and types of medical education publications by medical students and residents in one journal, it was not designed to assess the quality of these trainee-authored publications; future studies could use citation analysis and other methods to assess the impact of these publications. Moreover, more work is needed to determine whether early engagement in medical education scholarship persists over trainees’ careers. Though outside the scope of this study, future work could examine the relationship between trainee-authored medical education publications and future employment or engagement in academic medicine. Additionally, as previously mentioned, understanding the etiology of increased trainee authorship at the trainee, institution, and journal levels is important for identifying viable ways to increase trainee engagement in the academic community. Finally, further analysis should explore trainee authorship trends in other journals in medical education and medicine.
Among the 16 general medical education journals that met our inclusion criteria, only 1 journal provided reliable information on author roles in PubMed citations, and it is thus difficult to know whether our findings are generalizable to other medical education journals. Seven other medical education journals did include author role information in full-text articles, but they did so inconsistently and did not provide downloadable author role information, making large-scale retrospective analysis untenable. Nevertheless, as Academic Medicine is a leading journal in the field, we feel that our findings serve as an important benchmark. Additionally, although the core mission of Academic Medicine is to promote articles with a focus on medical education, there may have been a small number of articles that did not meet the definition of medical education content; we excluded nonscholarly work but were not able to systematically exclude “noneducational” articles.
We noted a discontinuity in total articles published in Academic Medicine between the years 2008 (223 total entries) and 2009 (383 total entries) across all publication types. The cause of this increase is unclear; the Academic Medicine editorial office could not identify any formal changes to policies or practices that would explain this increase.48 However, we do not expect that such absolute changes would affect the proportional prevalence rates we calculated in this manuscript.
Many general and specialty medical journals include a small number of medical education articles; we excluded such journals from this work because of feasibility concerns. An alternative, more resource-intensive approach for future study that would include such articles would be to analyze trainee authorship among a random sample of medical education articles across all medical journals. Although this article-level (rather than journal-level) approach would face similar limitations related to inconsistent identification of trainee authorship, it would likely produce more robust estimates of trainee authorship rates across multiple journals.
To identify trainee authors, we used an automated search strategy followed by manual confirmation; both approaches have the possibility for misclassification error. Nonetheless, in comparing our findings versus a prior publication examining only one year that used a purely manual strategy conducted by a different reviewer,15 we found nearly identical counts, indicating good validity to our approach here.
Owing to the delay between completion of scholarly work and publication, an author’s reported role at the time of publication may not accurately reflect that author’s role during the scholarly work. In the case of medical students becoming residents, this may lead to misclassification; in the case of trainees completing their training and assuming other roles (e.g., faculty), this may lead to underestimation of trainee scholarship. Where available, we attempted to incorporate the noted role at the time work was completed, but such notations were not consistently applied, and misclassification and underestimation of trainee work likely occurred.
A final limitation of this work is that manuscript publication, although an important measure of trainee engagement in scholarship, does not capture the full scope of trainee scholarly activities. We have witnessed medical students and residents contribute in important ways to scholarly projects that did not result in peer-reviewed publication; such activities were not assessed in this study but are an important area to quantify and assess.
Between 2002 and 2016, trainees increasingly authored medical education publications in Academic Medicine, suggesting growing activity of medical students and residents in the field of medical education. Additional study is needed to understand the drivers of this increased trainee authorship and the impact of these trainee-authored publications.
The authors would like to thank Dr. Sally Santen for her assistance and review of the manuscript.
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