INNOVATIONS
A Framework for Improving Resident Research Participation and Scholarly Output M.M. Manring, PhD, Julia A. Panzo, BA, and Joel L. Mayerson, MD Department of Orthopaedics, The Ohio State University, Columbus, Ohio OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that “faculty should encourage and support residents in scholarly activities.” There are no guidelines, however, to illustrate how this should be done, and only a small number of published reports offer examples of successful efforts to spur resident research. We sought to improve our residents’ participation in scholarly activities.
Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: Resident education, publications, scholarship, resident research COMPETENCIES: Medical Knowledge, Professionalism,
Practice-Based Learning and Improvement
DESIGN: We describe a multifaceted program to quickly
build resident scholarship at an orthopaedic department. SETTING: Large academic medical center in the Midwest-
ern United States. PARTICIPANTS: An experienced medical editor was
recruited to assist faculty and mentor residents in coordinating research projects and to direct publishing activity. Additional publishing requirements were added to the resident curriculum beyond those already required by the Accreditation Council for Graduate Medical Education. Residents were required to select a faculty research mentor to guide all research projects toward a manuscript suitable for submission to a peer-reviewed journal. Activities were monitored by the editor and the resident coordinator. RESULTS: Over 4 years, total department peer-reviewed
publications increased from 33 to 163 annually. Despite a decrease in resident complement, the number of peer-reviewed publications with a resident author increased from 6 in 2009 to 53 in 2012. CONCLUSIONS: The addition of an experienced medical
editor, changes in program requirements, and an increased commitment to promotion of resident research across the faculty led to a dramatic increase in resident publications. Our changes may be a model for other programs that have the financial resources and faculty commitment necessary to C 2014 achieve a rapid turnaround. ( J Surg 71:8-13. J
Correspondence: Inquiries to Joel L. Mayerson, MD, Department of Orthopaedics, Division of Musculoskeletal Oncology, The Ohio State University, James 1st Floor Ambulatory Clinic, 300 West 10th Avenue, Columbus, Ohio 43210; fax: þ1-614293-3747; e-mail: [email protected]
8
INTRODUCTION Scholarly activity is a requirement for both faculty and residents under the standards of the Accreditation Council Graduate Medical Education to “establish and maintain an environment of inquiry and scholarship with an active research component.” One of the primary measures of compliance with this requirement is the publication of original research or review articles in peer-reviewed journals.1 Publishing is a requirement for faculty advancement at many if not most institutions and has been linked by some studies to future academic achievement, and pursuit of fellowship opportunities, by resident physicians.2-4 Despite the importance of resident publishing, there are no established guidelines to the development of an effective program to promote it. Over the past decade, medical school faculty in a variety of training programs have described efforts to improve the research environment and quantify results.5-11 As noted by Penrose et al.,7 the most common barriers to resident participation in research are a lack of time, lack of infrastructure, lack of mentoring, and lack of financial support, and any attempt to improve research output by residents or faculty must deal with these obstacles. We describe our efforts during 2009 to 2012 to improve our orthopaedic department’s publications program, with a special emphasis on increased resident success in scholarly output. Our experience may be a useful guide for some departments to consider as they seek not only to meet Accreditation Council for Graduate Medical Education requirements but also to create an environment that is more conducive to research and professionally fulfilling for residents and faculty.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.07.011
METHODS In January 2009, our department ended a 2-year period of interim leadership, as a new chair was recruited with a charge to improve the department’s clinical, teaching, and research programs. An aggressive recruitment drive built the faculty from 16 with their primary appointment in orthopaedics at the end of 2009 to 35 by December 2012, and clinical and training opportunities were expanded in all orthopaedic subspecialties. However, a Resident Review Committee site review in 2009 identified several longstanding shortcomings, and the training program was placed on probation in spring of 2010. The resident complement was reduced from 30 (6 residents per year) to 29 in 2011 and 28 in 2012 as part of a probationary requirement to eventually step down the overall complement to 25 (5 per year). Before the probation was announced, the faculty had begun to address its shortcomings in residency training and scholarly effort. One of the major goals of the faculty and chair was to achieve a measurable increase in a verifiable index of resident scholarly accomplishment: peerreviewed publications. A secondary goal was to increase the number of resident research presentations at national and international conferences. Instead of having a single faculty member solely responsible for direction of the residency program, 2 associate program directors were appointed from the faculty: 1 for research and 1 for curriculum. They worked together to establish a completely revised resident research policy that instituted 4 requirements for each resident: (1) to prepare a review article or systematic review of the literature during their postgraduate year (PGY)-2 or PGY3 year; (2) to complete 1 clinical or laboratory research project for presentation at our annual research day; (3) to prepare and submit at least 1 manuscript based on his or her research project to a peer-reviewed journal by the end of their PGY-5 year; and (4) to mentor, during their PGY-5 year, 1 junior resident in the preparation of a review article or systematic review. Secondly, faculty members were required to take a larger role in individual resident’s research. Each resident was assigned research advisors, at least 1 clinical and 1 research faculty member, during the PGY-1 year. Regular meetings were established to monitor topic development for manuscripts, presentations, and funding submissions to granting agencies that focus on orthopaedic resident research, such as the Orthopaedic Research and Education Foundation (OREF). The research advisors are charged with monitoring an individual resident’s progress through the 4 goals outlined before. Faculty members were assigned to deliver didactic lectures to residents on research methodologies, such as study design, statistical analysis, and university and federal regulations.
Finally, the department also expected to increase the overall number of scholarly publications to at least reflect its growth in faculty, and thus made a major investment in personnel by recruiting an experienced medical editor from an orthopaedic department in another state. The editor is not a basic scientist or clinician but a PhD in liberal arts with 25 years experience in the publishing field. His assignment was to work with faculty and residents in several defined areas related to making departmental research more efficient in developing written material (manuscript submissions, revisions, grant applications, protocols, etc.). In the case of rejected manuscripts, the editor worked with faculty and residents to revise for resubmission to another journal, continuing to shepherd the manuscript to eventual publication. We reviewed our publication record over the past 4 years to determine whether and to what extent our changes in curriculum and staffing affected our scholarly output, with a primary measure of peer-reviewed publications. We also reviewed faculty productivity, both research (publications) and clinical output (relative value units [wRVUs]) during the same study period to learn whether our changes affected faculty.
RESULTS During 2009 to 2012, the number of residents in the program decreased slightly, from 30 to 28, as the probationary decrease in complement began to take effect. However, the number of resident publications increased dramatically. As recently as calendar 2006, no department publication listed a resident coauthor. In 2009, 6 manuscripts had resident coauthors. That increased to 28 in 2010, 49 in 2011, and 53 in 2012 (Fig. 1). As the number of residents in the complement actually declined, the number of publications with resident authors was approximately 9 times greater. Residents coauthored more systematic reviews, as expected given our requirements, but displayed a much more dramatic increase in the number of original studies (Table 1), particularly clinical studies as opposed to basic science, and residents were listed as first author in an increased number of publications (Table 2). The growth in resident publications reflects a similar growth in the number of peer-reviewed publications overall, from 33 in 2009 to 163 in 2012 (Fig. 2). Although the number of faculty roughly doubled, the number of overall publications increased nearly fivefold. To determine whether the growth in the total number of faculty was the only explanation for the overall increase in publications, we examined the records of 13 faculty members who were present at the end of 2008 and remained on the faculty at the end of 2012. Those 13 faculty members produced a total of 19 peer-reviewed publications in 2008 and 18 in 2009, but 52 in 2010, 65 in 2011, and 59 in 2012. Of those 13 faculty members, 10 were surgeons and 3 researchers. The 10 clinicians published 11 manuscripts in 2009, 51 in 2010, 58 in 2011, and 54 in 2012.
Journal of Surgical Education Volume 71/Number 1 January/February 2014
9
FIGURE 1. Resident complement and publications with a resident author, 2006 to 2012.
A review of wRVUs was performed to determine whether the increase in published research among the 10 clinical faculty members was accompanied by a decrease in their clinical output as the overall faculty grew in numbers. wRVUs were consistently around 95,000 for the core faculty during the study period (Fig. 3); there was no statistically significant (p o 0.05) relationship between wRVUs and publications, either of the core clinical faculty or the faculty as a whole. More modest increases were seen in the secondary measurement of scholarly activity. In the 2008 to 2009 academic year, residents made 15 presentations at national or international conferences. That rose to 24 in 2009-2010 but fell to 19 in 2011-2012. Of these 58 presentations, 22 have led to publication in peer-reviewed journals at the time of writing this article. Based on our department’s growth in faculty, clinical improvement, and improved curriculum, full accreditation for our residency program was restored in 2011.
DISCUSSION Various approaches have been proposed to increase department and resident research productivity. Some are specific TABLE 1. Peer-Reviewed Manuscripts With Resident Coauthors From Calendar Year 2009 to 2012, by Type of Article 2009 2010 2011 2012 Case reports/series Topic reviews Systematic reviews/metaanalyses Original research Total 10
0 1
6 3
12 12
13 5
0
6
9
8
5 6
13 28
16 49
27 53
to academic departments, whereas others serve whole medical schools. For example, Texas Tech University’s Amarillo campus, with 80 total faculty members and 80 residents, developed a Research Assistance United, with 3 full-time staff members, which focused on helping faculty shepherd projects from IRB approval to publication. The school reported increases in IRB-approved projects, publications, and faculty satisfaction.5 At the Medical University of South Carolina, the Department of Family Medicine created a program to immerse PGY2 residents in research techniques and require development of abstracts and manuscripts.12 Most recently, the Department of Obstetrics and Gynecology at the Texas Tech Health Sciences Center in Lubbock, a program with approximately 12 faculty members and 12 residents, dedicated clinical funds to the creation of a postdoctoral research position dedicated to assisting faculty and residents with research projects. That department reports increases in presentations, grants submitted and funded, and manuscripts submitted.7 Successful efforts to increase scholarly accomplishments take on different scale and emphasize different measures of success, but they would appear to have at least 2 basic requirements in common: faculty commitment and dedicated staff. TABLE 2. Description of Residents’ Publications. Basic Science Includes Biomechanical, Molecular, Cadaveric, and Similar Studies; Clinical Includes Prospective/Retrospective Cohorts, Case Reports and Series, and Techniques; Other Includes Topic Reviews, Systematic Reviews, Meta-analyses, and Surveys
2009 2010 2011 2012
Resident as First Author
Basic Science
1 22 37 31
0 7 7 8
Clinical Other 5 14 22 31
1 7 20 14
Journal of Surgical Education Volume 71/Number 1 January/February 2014
FIGURE 2. Total department peer-reviewed publications, 2006 to 2012.
We learned that faculty commitment to increased, measurable resident research played a large role in the increase of overall department publications; the rising tide lifted both ships. Residents and faculty, with a new commitment to work together, did not simply produce one additional publication per resident over our study period, which would meet the curricular requirements, but exceeded that goal almost immediately, as total publications more than doubled in the first full year of the program, from 33 to 85. Additionally, although the number of systematic reviews grew, the number of original research papers (clinical and biomechanical studies) grew much more dramatically, from 5 in 2009 to 31 in 2012. This suggests to us an increased interest in research among our residents beyond the minimum publication requirements.
Regarding staffing, our department was relatively small, but projected to become medium sized, as it did over about 2 years, and our chair determined that a dedicated staff position would be justified to serve the needs of approximately 40 faculty members and 30 residents. The results have exceeded our expectations, as overall publications grew much more quickly than our faculty numbers. At any given time, our department usually has approximately 75 manuscripts in some stage of the submission or revision process as well as approximately 25 accepted publications that await proofing. This in our view has easily justified the establishment of a full-time medical editor. One important contribution of a medical editor may be relatively easily overlooked. Our editor is responsible for monitoring the progress of all manuscripts from their initial drafting to their publication, but also to promoting their revision and resubmission after rejection. A large number of initial submissions to peer-reviewed journals are rejected. For example, a recent study of 1173 manuscripts submitted to the Journal of Bone and Joint Surgery from 2004 to 2005 showed that 918 (78%) were rejected.13 That same study, however, demonstrated that within 5 years after rejection, 696 (76%) of the rejected studies had been published in another journal. Clearly, persistence is essential to seeing one’s work published. It is our observation that some faculty and residents may see initial rejection of their work as confirmation that it is not suitable for publication, rather than an indication that it needs more work or was not suitable for a particular journal. Our editor serves as a kind of “in-house referee” who works with authors on strategies for improving manuscripts and ensuring that they are revised and resubmitted in a timely fashion. This collaborative process among the editor, faculty, and residents is
FIGURE 3. Publications by 10 core clinical faculty members who were present continuously during the study period compared with their wRVUs (in thousands). Although publications among this faculty cohort rose dramatically, there was no statistical significance (p o 0.05) in wRVUs. Journal of Surgical Education Volume 71/Number 1 January/February 2014
11
extremely important in making the process of manuscript submission more efficient but is also helpful in providing an internal push to continually expedite the process from initial submission to manuscript publication even when multiple journals have been involved in the journey. Departments that wish to publish more, regardless of whether they hire a medical editor, may benefit from the presence of a faculty or staff member who is responsible for monitoring the progress of submissions and at times giving faculty and residents a push. It is important to note, of course, that the employment of medical editor or other staff would not mean much if the department leadership, faculty, and residents do not have incentives to perform scholarship. In our case, for example, completing a publishable manuscript was a requirement of the residency program, and faculty members were required to be involved in the project. Our report has several limitations. We recognize that our growth in publications took place during a period in which our total faculty numbers increased by an unusual amount. Although our increase in publications greatly exceeded our growth in raw numbers, we recruited new faculty members with the expectation that they would take active roles in research projects and pursue peer-reviewed publication. A change in department expectations, especially during the recruitment process, must play a role in improving scholarly performance, although this is difficult to quantify. We believe that providing infrastructure, particularly staffing, is demonstrably crucial to ensuring that new faculty meet enhanced research expectations. Moreover, as our analysis showed, 13 core faculty who collectively published 19 and 18 papers in the 2 years before our changes are now publishing more than 50 papers annually, suggesting that an increase in faculty alone is insufficient to explain the growth in publications. Secondly, we believe it is important to note that resident publications in peer-reviewed journals have reportedly increased since the establishment of the 80-hour workweek, which presumably gave residents additional time to pursue research projects.14 The time frame of our present study, however, takes place entirely after the institution of new work rules. Finally, and perhaps most significantly, we recognize that not every department has the resources to hire a medical editor. In our metropolitan area (Columbus, OH), our university’s salary range for a “technical editor” falls between $50,000 and $60,000. The candidate pool typically consists of liberal arts majors (English and Journalism) who have been employed in publishing environments at our university or in the private sector. We believe there is probably great variability in the availability of such professionals as well as the likely salary, depending on the geographic location and job market. In addition, there is no formal degree, diploma, or certification in medical writing, and training usually takes place on the job.15 Smaller departments in related disciplines (for example, orthopaedics, rehabilitation, and radiology) 12
might consider sharing editorial assistance to justify the expense.
CONCLUSION We describe a program of enhanced staffing, curricular changes, faculty involvement, and increased expectations, which was aimed at increasing resident scholarly participation and led to a dramatic increase in our department’s research outcomes, as measured by peer-reviewed publications. We believe that other departments, as they review their goals and the resources they can apply, may be able to borrow lessons from our experience to improve resident training and enhance faculty research productivity.
REFERENCES 1. Accreditation Council for Graduate Medical Education.
Common program requirements 2011. (Accessed Dec. 12, 2012, at Available at: 〈http://www.acgme.org/ acgmeweb/Portals/0/dh_dutyhoursCommonPR0701; 2007.pdf〉. 2. Yang G, Zaid UB, Erickson BA, Blaschko SD, Carroll
PR, Breyer BN. Urology resident publication output and its relationship to future academic achievement. J Urol. 2011;185:642-646. 3. Crowley RW, Asthagiri AR, Starke RM, Zusman EE,
Chiocca EA, Lonser RR. In-training factors predictive of choosing and sustaining a productive academic career path in neurological surgery. Neurosurgery. 2012;70:1024-1032. 4. Rezek I, McDonald RJ, Kallmes DF. Pre-residency
publication rate strongly predicts future academic radiology potential. Acad Radiol. 2012;19:632-634. 5. Eder M, Pierce JR Jr.. Innovations in faculty develop-
ment: study of a research assistance unit designed to assist clinician-educators with research. South Med J. 2011;104:647-650. 6. Batcheller J, Kirksey KM, VanDyke Y, Armstrong
ML. Publish or perish: writing clinical manuscripts suitable for publication. J Contin Educ Nurs. 2012;43:44-48. 7. Penrose LL, Yeomans ER, Praderio C, Prien SD. An
incremental approach to improving scholarly activity. J Grad Med Educ. 2012;4:496-499. 8. Roane DM, Inan E, Haeri S, Galynker II. Ensuring
research competency in psychiatric residency training. Acad Psychiatry. 2009;33:215-220.
Journal of Surgical Education Volume 71/Number 1 January/February 2014
9. Crawford P, Seehusen D. Scholarly activity in family
medicine residency programs: a national survey. Fam Med. 2011;43:311-317. 10. Smith-Barbaro P, Fulda KG, Coleridge ST. A divisio-
residents: one program’s solution. J Grad Med Educ. 2011;3:379-382. 13. Okike K, Kocher MS, Nwachukwu BU, Mehlman
nal approach to enhancing research among osteopathic family practice residents. J Am Osteopath Assoc. 2004;104:177-179.
CT, Heckman JD, Bhandari M. The fate of manuscripts rejected by The Journal of Bone and Joint Surgery (American Volume). J Bone Joint Surg Am. 2012;94:e130.
11. Coleridge ST, Smith-Barbaro P, Knisley C. A practical
14. Namdari S, Baldwin KD, Weinraub B, Mehta S.
method for increasing scholarly activity in an academic family medicine department. Teach Learn Med. 2004;16:181-185.
Changes in the number of resident publications after inception of the 80-hour work week. Clin Orthop Relat Res. 2010;468:2278-2283.
12. Carek PJ, Dickerson LM, Diaz VA, Steyer TE.
15. Sharma S. How to become a competent medical
Addressing the scholarly activity requirements for
writer? Perspect Clin Res. 2010;1:33-37.
Journal of Surgical Education Volume 71/Number 1 January/February 2014
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A Framework for Improving Resident Research Participation and Scholarly Output M.M. Manring, PhD, Julia A. Panzo, BA, and Joel L. Mayerson, MD Department of Orthopaedics, The Ohio State University, Columbus, Ohio OBJECTIVES: The Accreditation Council for Graduate Medical Education requires that “faculty should encourage and support residents in scholarly activities.” There are no guidelines, however, to illustrate how this should be done, and only a small number of published reports offer examples of successful efforts to spur resident research. We sought to improve our residents’ participation in scholarly activities.
Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: Resident education, publications, scholarship, resident research COMPETENCIES: Medical Knowledge, Professionalism,
Practice-Based Learning and Improvement
DESIGN: We describe a multifaceted program to quickly
build resident scholarship at an orthopaedic department. SETTING: Large academic medical center in the Midwest-
ern United States. PARTICIPANTS: An experienced medical editor was
recruited to assist faculty and mentor residents in coordinating research projects and to direct publishing activity. Additional publishing requirements were added to the resident curriculum beyond those already required by the Accreditation Council for Graduate Medical Education. Residents were required to select a faculty research mentor to guide all research projects toward a manuscript suitable for submission to a peer-reviewed journal. Activities were monitored by the editor and the resident coordinator. RESULTS: Over 4 years, total department peer-reviewed
publications increased from 33 to 163 annually. Despite a decrease in resident complement, the number of peer-reviewed publications with a resident author increased from 6 in 2009 to 53 in 2012. CONCLUSIONS: The addition of an experienced medical
editor, changes in program requirements, and an increased commitment to promotion of resident research across the faculty led to a dramatic increase in resident publications. Our changes may be a model for other programs that have the financial resources and faculty commitment necessary to C 2014 achieve a rapid turnaround. ( J Surg 71:8-13. J
Correspondence: Inquiries to Joel L. Mayerson, MD, Department of Orthopaedics, Division of Musculoskeletal Oncology, The Ohio State University, James 1st Floor Ambulatory Clinic, 300 West 10th Avenue, Columbus, Ohio 43210; fax: þ1-614293-3747; e-mail: [email protected]
8
INTRODUCTION Scholarly activity is a requirement for both faculty and residents under the standards of the Accreditation Council Graduate Medical Education to “establish and maintain an environment of inquiry and scholarship with an active research component.” One of the primary measures of compliance with this requirement is the publication of original research or review articles in peer-reviewed journals.1 Publishing is a requirement for faculty advancement at many if not most institutions and has been linked by some studies to future academic achievement, and pursuit of fellowship opportunities, by resident physicians.2-4 Despite the importance of resident publishing, there are no established guidelines to the development of an effective program to promote it. Over the past decade, medical school faculty in a variety of training programs have described efforts to improve the research environment and quantify results.5-11 As noted by Penrose et al.,7 the most common barriers to resident participation in research are a lack of time, lack of infrastructure, lack of mentoring, and lack of financial support, and any attempt to improve research output by residents or faculty must deal with these obstacles. We describe our efforts during 2009 to 2012 to improve our orthopaedic department’s publications program, with a special emphasis on increased resident success in scholarly output. Our experience may be a useful guide for some departments to consider as they seek not only to meet Accreditation Council for Graduate Medical Education requirements but also to create an environment that is more conducive to research and professionally fulfilling for residents and faculty.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.07.011
METHODS In January 2009, our department ended a 2-year period of interim leadership, as a new chair was recruited with a charge to improve the department’s clinical, teaching, and research programs. An aggressive recruitment drive built the faculty from 16 with their primary appointment in orthopaedics at the end of 2009 to 35 by December 2012, and clinical and training opportunities were expanded in all orthopaedic subspecialties. However, a Resident Review Committee site review in 2009 identified several longstanding shortcomings, and the training program was placed on probation in spring of 2010. The resident complement was reduced from 30 (6 residents per year) to 29 in 2011 and 28 in 2012 as part of a probationary requirement to eventually step down the overall complement to 25 (5 per year). Before the probation was announced, the faculty had begun to address its shortcomings in residency training and scholarly effort. One of the major goals of the faculty and chair was to achieve a measurable increase in a verifiable index of resident scholarly accomplishment: peerreviewed publications. A secondary goal was to increase the number of resident research presentations at national and international conferences. Instead of having a single faculty member solely responsible for direction of the residency program, 2 associate program directors were appointed from the faculty: 1 for research and 1 for curriculum. They worked together to establish a completely revised resident research policy that instituted 4 requirements for each resident: (1) to prepare a review article or systematic review of the literature during their postgraduate year (PGY)-2 or PGY3 year; (2) to complete 1 clinical or laboratory research project for presentation at our annual research day; (3) to prepare and submit at least 1 manuscript based on his or her research project to a peer-reviewed journal by the end of their PGY-5 year; and (4) to mentor, during their PGY-5 year, 1 junior resident in the preparation of a review article or systematic review. Secondly, faculty members were required to take a larger role in individual resident’s research. Each resident was assigned research advisors, at least 1 clinical and 1 research faculty member, during the PGY-1 year. Regular meetings were established to monitor topic development for manuscripts, presentations, and funding submissions to granting agencies that focus on orthopaedic resident research, such as the Orthopaedic Research and Education Foundation (OREF). The research advisors are charged with monitoring an individual resident’s progress through the 4 goals outlined before. Faculty members were assigned to deliver didactic lectures to residents on research methodologies, such as study design, statistical analysis, and university and federal regulations.
Finally, the department also expected to increase the overall number of scholarly publications to at least reflect its growth in faculty, and thus made a major investment in personnel by recruiting an experienced medical editor from an orthopaedic department in another state. The editor is not a basic scientist or clinician but a PhD in liberal arts with 25 years experience in the publishing field. His assignment was to work with faculty and residents in several defined areas related to making departmental research more efficient in developing written material (manuscript submissions, revisions, grant applications, protocols, etc.). In the case of rejected manuscripts, the editor worked with faculty and residents to revise for resubmission to another journal, continuing to shepherd the manuscript to eventual publication. We reviewed our publication record over the past 4 years to determine whether and to what extent our changes in curriculum and staffing affected our scholarly output, with a primary measure of peer-reviewed publications. We also reviewed faculty productivity, both research (publications) and clinical output (relative value units [wRVUs]) during the same study period to learn whether our changes affected faculty.
RESULTS During 2009 to 2012, the number of residents in the program decreased slightly, from 30 to 28, as the probationary decrease in complement began to take effect. However, the number of resident publications increased dramatically. As recently as calendar 2006, no department publication listed a resident coauthor. In 2009, 6 manuscripts had resident coauthors. That increased to 28 in 2010, 49 in 2011, and 53 in 2012 (Fig. 1). As the number of residents in the complement actually declined, the number of publications with resident authors was approximately 9 times greater. Residents coauthored more systematic reviews, as expected given our requirements, but displayed a much more dramatic increase in the number of original studies (Table 1), particularly clinical studies as opposed to basic science, and residents were listed as first author in an increased number of publications (Table 2). The growth in resident publications reflects a similar growth in the number of peer-reviewed publications overall, from 33 in 2009 to 163 in 2012 (Fig. 2). Although the number of faculty roughly doubled, the number of overall publications increased nearly fivefold. To determine whether the growth in the total number of faculty was the only explanation for the overall increase in publications, we examined the records of 13 faculty members who were present at the end of 2008 and remained on the faculty at the end of 2012. Those 13 faculty members produced a total of 19 peer-reviewed publications in 2008 and 18 in 2009, but 52 in 2010, 65 in 2011, and 59 in 2012. Of those 13 faculty members, 10 were surgeons and 3 researchers. The 10 clinicians published 11 manuscripts in 2009, 51 in 2010, 58 in 2011, and 54 in 2012.
Journal of Surgical Education Volume 71/Number 1 January/February 2014
9
FIGURE 1. Resident complement and publications with a resident author, 2006 to 2012.
A review of wRVUs was performed to determine whether the increase in published research among the 10 clinical faculty members was accompanied by a decrease in their clinical output as the overall faculty grew in numbers. wRVUs were consistently around 95,000 for the core faculty during the study period (Fig. 3); there was no statistically significant (p o 0.05) relationship between wRVUs and publications, either of the core clinical faculty or the faculty as a whole. More modest increases were seen in the secondary measurement of scholarly activity. In the 2008 to 2009 academic year, residents made 15 presentations at national or international conferences. That rose to 24 in 2009-2010 but fell to 19 in 2011-2012. Of these 58 presentations, 22 have led to publication in peer-reviewed journals at the time of writing this article. Based on our department’s growth in faculty, clinical improvement, and improved curriculum, full accreditation for our residency program was restored in 2011.
DISCUSSION Various approaches have been proposed to increase department and resident research productivity. Some are specific TABLE 1. Peer-Reviewed Manuscripts With Resident Coauthors From Calendar Year 2009 to 2012, by Type of Article 2009 2010 2011 2012 Case reports/series Topic reviews Systematic reviews/metaanalyses Original research Total 10
0 1
6 3
12 12
13 5
0
6
9
8
5 6
13 28
16 49
27 53
to academic departments, whereas others serve whole medical schools. For example, Texas Tech University’s Amarillo campus, with 80 total faculty members and 80 residents, developed a Research Assistance United, with 3 full-time staff members, which focused on helping faculty shepherd projects from IRB approval to publication. The school reported increases in IRB-approved projects, publications, and faculty satisfaction.5 At the Medical University of South Carolina, the Department of Family Medicine created a program to immerse PGY2 residents in research techniques and require development of abstracts and manuscripts.12 Most recently, the Department of Obstetrics and Gynecology at the Texas Tech Health Sciences Center in Lubbock, a program with approximately 12 faculty members and 12 residents, dedicated clinical funds to the creation of a postdoctoral research position dedicated to assisting faculty and residents with research projects. That department reports increases in presentations, grants submitted and funded, and manuscripts submitted.7 Successful efforts to increase scholarly accomplishments take on different scale and emphasize different measures of success, but they would appear to have at least 2 basic requirements in common: faculty commitment and dedicated staff. TABLE 2. Description of Residents’ Publications. Basic Science Includes Biomechanical, Molecular, Cadaveric, and Similar Studies; Clinical Includes Prospective/Retrospective Cohorts, Case Reports and Series, and Techniques; Other Includes Topic Reviews, Systematic Reviews, Meta-analyses, and Surveys
2009 2010 2011 2012
Resident as First Author
Basic Science
1 22 37 31
0 7 7 8
Clinical Other 5 14 22 31
1 7 20 14
Journal of Surgical Education Volume 71/Number 1 January/February 2014
FIGURE 2. Total department peer-reviewed publications, 2006 to 2012.
We learned that faculty commitment to increased, measurable resident research played a large role in the increase of overall department publications; the rising tide lifted both ships. Residents and faculty, with a new commitment to work together, did not simply produce one additional publication per resident over our study period, which would meet the curricular requirements, but exceeded that goal almost immediately, as total publications more than doubled in the first full year of the program, from 33 to 85. Additionally, although the number of systematic reviews grew, the number of original research papers (clinical and biomechanical studies) grew much more dramatically, from 5 in 2009 to 31 in 2012. This suggests to us an increased interest in research among our residents beyond the minimum publication requirements.
Regarding staffing, our department was relatively small, but projected to become medium sized, as it did over about 2 years, and our chair determined that a dedicated staff position would be justified to serve the needs of approximately 40 faculty members and 30 residents. The results have exceeded our expectations, as overall publications grew much more quickly than our faculty numbers. At any given time, our department usually has approximately 75 manuscripts in some stage of the submission or revision process as well as approximately 25 accepted publications that await proofing. This in our view has easily justified the establishment of a full-time medical editor. One important contribution of a medical editor may be relatively easily overlooked. Our editor is responsible for monitoring the progress of all manuscripts from their initial drafting to their publication, but also to promoting their revision and resubmission after rejection. A large number of initial submissions to peer-reviewed journals are rejected. For example, a recent study of 1173 manuscripts submitted to the Journal of Bone and Joint Surgery from 2004 to 2005 showed that 918 (78%) were rejected.13 That same study, however, demonstrated that within 5 years after rejection, 696 (76%) of the rejected studies had been published in another journal. Clearly, persistence is essential to seeing one’s work published. It is our observation that some faculty and residents may see initial rejection of their work as confirmation that it is not suitable for publication, rather than an indication that it needs more work or was not suitable for a particular journal. Our editor serves as a kind of “in-house referee” who works with authors on strategies for improving manuscripts and ensuring that they are revised and resubmitted in a timely fashion. This collaborative process among the editor, faculty, and residents is
FIGURE 3. Publications by 10 core clinical faculty members who were present continuously during the study period compared with their wRVUs (in thousands). Although publications among this faculty cohort rose dramatically, there was no statistical significance (p o 0.05) in wRVUs. Journal of Surgical Education Volume 71/Number 1 January/February 2014
11
extremely important in making the process of manuscript submission more efficient but is also helpful in providing an internal push to continually expedite the process from initial submission to manuscript publication even when multiple journals have been involved in the journey. Departments that wish to publish more, regardless of whether they hire a medical editor, may benefit from the presence of a faculty or staff member who is responsible for monitoring the progress of submissions and at times giving faculty and residents a push. It is important to note, of course, that the employment of medical editor or other staff would not mean much if the department leadership, faculty, and residents do not have incentives to perform scholarship. In our case, for example, completing a publishable manuscript was a requirement of the residency program, and faculty members were required to be involved in the project. Our report has several limitations. We recognize that our growth in publications took place during a period in which our total faculty numbers increased by an unusual amount. Although our increase in publications greatly exceeded our growth in raw numbers, we recruited new faculty members with the expectation that they would take active roles in research projects and pursue peer-reviewed publication. A change in department expectations, especially during the recruitment process, must play a role in improving scholarly performance, although this is difficult to quantify. We believe that providing infrastructure, particularly staffing, is demonstrably crucial to ensuring that new faculty meet enhanced research expectations. Moreover, as our analysis showed, 13 core faculty who collectively published 19 and 18 papers in the 2 years before our changes are now publishing more than 50 papers annually, suggesting that an increase in faculty alone is insufficient to explain the growth in publications. Secondly, we believe it is important to note that resident publications in peer-reviewed journals have reportedly increased since the establishment of the 80-hour workweek, which presumably gave residents additional time to pursue research projects.14 The time frame of our present study, however, takes place entirely after the institution of new work rules. Finally, and perhaps most significantly, we recognize that not every department has the resources to hire a medical editor. In our metropolitan area (Columbus, OH), our university’s salary range for a “technical editor” falls between $50,000 and $60,000. The candidate pool typically consists of liberal arts majors (English and Journalism) who have been employed in publishing environments at our university or in the private sector. We believe there is probably great variability in the availability of such professionals as well as the likely salary, depending on the geographic location and job market. In addition, there is no formal degree, diploma, or certification in medical writing, and training usually takes place on the job.15 Smaller departments in related disciplines (for example, orthopaedics, rehabilitation, and radiology) 12
might consider sharing editorial assistance to justify the expense.
CONCLUSION We describe a program of enhanced staffing, curricular changes, faculty involvement, and increased expectations, which was aimed at increasing resident scholarly participation and led to a dramatic increase in our department’s research outcomes, as measured by peer-reviewed publications. We believe that other departments, as they review their goals and the resources they can apply, may be able to borrow lessons from our experience to improve resident training and enhance faculty research productivity.
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9. Crawford P, Seehusen D. Scholarly activity in family
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