Research education in obstetrics and gynecology: how are we doing?

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Research education in obstetrics and gynecology: how are we doing? Kimberly Kenton, MD, MS; Linda Brubaker, MD, MS OBJECTIVE: This study was undertaken to determine how obstetrics and gynecology residency programs are teaching residents about research. STUDY DESIGN: Obstetrics and gynecology program directors in the United States and Canada completed a 15-question survey about their current research education programs, their perception of the most important components of resident research education, and how well prepared graduating residents were for a variety of research-related activities. RESULTS: One hundred thirty-two of 213 (62%) program directors

completed the survey. Ninety-five percent required residents complete

a research project to graduate. Research topics were more commonly taught via journal clubs (84%) and informal apprenticeships (78%). Less than half of the programs provided didactic presentations on clinical trial design and biostatistics (47%) or statistical software (38%). CONCLUSION: Although nearly all of the sampled obstetrics and gynecology residency programs require resident research projects, most provide limited resources or formal education on clinical research design and biostatistics.

Key words: research curriculum, research education, resident research

Cite this article as: Kenton K, Brubaker L. Research education in obstetrics and gynecology: how are we doing? Am J Obstet Gynecol 2007;197:532.e1-532.e4.

T

wo requirements common to all residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) are as follows: (1) that the faculty maintains an environment of scholarship and an active research component; and (2) that residents have and take advantage of opportunities to participate in research or other scholarly activities.1 Although the ACGME clearly defines “scholarly activity” for faculty, the requirements for residents are less explicit (Table 1), leaving this to the interpretation of individual programs and specialties. As a result, a From the Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Obstetrics and Gynecology and Urology, Loyola University Medical Center, Maywood, IL. Presented at the annual meeting of the Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics, Salt Lake City, UT, March 7-10, 2007. Received Mar. 15, 2007; revised May 31, 2007; accepted Jul. 23, 2007. Reprints not available from the authors. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.07.030

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variety of activities can be classified as “scholarship,” including journal clubs, teaching conferences and other research projects. A recent survey of Internal Medicine program directors found that an ACGME Residency Review Committees (RRC) citation for failure to demonstrate scholarly activities was a strong predictor of a shortened interval between RRC site review visits.2 Multiple studies have documented the finding that resident research enhances patient care as well as overall medical knowledge.3,4 In addition, resident research aids clinician development of analytical and communication skills, as well as lifelong learning.5 Despite ACGME requirements and the benefits of resident research on future practice, numerous barriers to successful research training have been reported in other medical disciplines, including lack of mentoring, time, and resources; lack of financial support; and lack of curricular time.6,3,7-9 Given the clearly established requirements and importance of resident research, we sought to determine how obstetrics and gynecology residency program directors incorporated resident research education into their training programs.

American Journal of Obstetrics & Gynecology NOVEMBER 2007

M ATERIALS AND M ETHODS We invited all United States and Canadian obstetric and gynecology residency program directors attending the Association of Professors for Gynecologists and Obstetricians Annual Meeting in March of 2006 to complete a 15-question written survey about resident research education. The survey queried program directors about their program’s research requirements and specific components of their research curriculum. They were also asked to rank 11 research-related items from most important to least important (Table 2). Program directors were also queried about the percentage of graduating residents who have continued to do research over the last 5 years and graduating residents’ preparedness to design a research protocol, write a research protocol, prepare an institutional review board (IRB) submission, analyze and interpret results, prepare an abstract, write a manuscript, and interpret the published literature. SPSS Version 13 (SPSS, Inc, Chicago, IL) was used for data management and analysis. The Mann-Whitney test was used to compare independent groups with respect to continuous variables. Spearman’s correlations were used to

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TABLE 1

TABLE 3

Accreditation council for graduate medical education scholarship requirements (http://www.acgme.org)

Obstetrics and gynecology residency programs research curriculum

Faculty The responsibility for establishing and maintaining an environment of inquiry and scholarship rests with the faculty, and an active research component must be included in each program. Scholarship is defined as the following: a. the scholarship of discovery, as evidenced by peer-reviewed funding or publication of original research in a peer-reviewed journal; b. the scholarship of dissemination, as evidenced by review articles or chapters in textbooks; c. the scholarship of application, as evidenced by the publication or presentation of, for example, case reports or clinical series at local, regional, or national professional and scientific society meetings. Complementary to the above scholarship is the regular participation in of the teaching staff in clinical discussions, journal clubs and research conferences in a manner that promotes a spirit of inquiry and scholarship (eg, the offering of guidance and technical support for residents involved in research such as research design and statistical analysis); and the provision of support for residents’ participation, as appropriate, in scholarly activities. Residents Each program must provide an opportunity for residents to participate in research or other scholarly activities, and residents must participate actively in such scholarly activities.

compare proportion of residents doing research after graduation with levels of perceived preparedness. All tests were considered significant at .05 level and no 1-sided tests were used.

TABLE 2

Program directors ranking of resident research education Ability to interpret the literature

2

Understand how to design research projects

1

Understand ethics of human subject research

3

Understand how to perform basic statistical analysis

4

...........................................................................................................

...........................................................................................................

...........................................................................................................

...........................................................................................................

Able to design research projects

5

Able to prepare an abstract

6

Know how to submit an IRB proposal

7

Able to perform basic statistical analysis

8

Present research at a local meeting (own institution)

9

........................................................................................................... ...........................................................................................................

...........................................................................................................

...........................................................................................................

...........................................................................................................

Submit manuscript for publication

10

Present research at a national meeting

11

...........................................................................................................

...........................................................................................................

Most important ⫽ 1; least important ⫽ 11.

R ESULTS One hundred thirty-two of 213 (62%) United States and Canadian obstetric and gynecology residency program directors completed the survey. Sixtythree percent of respondents were from university-based programs, 35% community programs, and 2% military programs. There were no significant differences in any parameters measured between university and community programs. Ninety-five percent of responding programs required residents to complete a research project for graduation. None of the 6 programs without a resident research requirement were university based. The length of time programs had required a research project was less than 5 years in 15%, 5 years or more and less than 10 years in 25%, 10 years or more and less than 15 years in 24%, and 15 years or more in 36%. Eighty-nine percent of residency program directors report that they were actively involved in research. Only 43 of the 127 programs (33%) with a research requirement provided a specified research rotation, most commonly in the third year (63%). Less commonly, the research rotation occurred in the first or second years (22%) or the fourth year (15%). The duration of the majority (87%) of the research rotations

Research curriculum

% of Programs

Journal clubs

84%

Informal apprenticeship with faculty mentor

78%

Designated biostatistician

58%

Formal with regularly scheduled research meetings and didactics

47%

Didactics on biostatistics and epidemiology

47%

Access to statistical software program

38%

...........................................................................................................

........................................................................................................... ...........................................................................................................

...........................................................................................................

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was 4 weeks. Residents in the remaining programs completed their research during their regularly scheduled rotations and/or when they were off duty. Table 3 contains the percentage of residency programs that offer particular aspects of a research curriculum. The majority of programs had regularly scheduled journal clubs and used an apprenticeship model for research education. Less than half offered regularly scheduled research meetings with didactics on research design, biostatistics and epidemiology, or access to statistical software for data entry and management. Table 2 contains program director’s ratings of 11 components of resident research education from most important (1) to least important (11). The majority of program directors (78%) ranked resident’s ability to interpret the published literature as most important. They also though it was important for residents to have an understanding of how to design and analyze research, although they believed presenting and publishing were less important. Program directors estimated that 16% ⫾ 13% of graduating residents continued research activities after graduation. Table 4 shows the proportion of program directors who reported that their residents were well prepared for various aspects of clinical research on gradua-

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Meeting Papers tion. Almost all reported that graduating residents were prepared or very prepared to interpret the literature, and that residents were less prepared to write a research protocol, submit a proposal to the IRB, or to write a manuscript. Two structured components of a research education program were significantly associated with several aspects of successful resident research education: (1) having a specified research rotation; and (2) having a formal research curriculum with regular meetings and didactics. Residents in programs with a specified research rotation were significantly more likely to continue to do research after graduation (22% ⫾ 14% vs 13% ⫾ 12%, P ⬍ .0005) and be able to write a research protocol independently (P ⫽ .018). Residents who were exposed to a formal research curriculum were more prepared to interpret the published literature (P ⬍ .0005), write a research protocol (P ⫽ .047), and write a manuscript (P ⫽ .06). The percentage of graduating residents who continue to do research after graduation was correlated with preparedness to: write a research proposal (Spearman’s ␳ ⫽ .313, P ⫽ .001), design a research project (Spearman’s ␳ ⫽ .297, P ⫽ .001), write a manuscript (Spearman’s ␳ ⫽ .264, P ⫽ .004), and interpret the published literature (Spearman’s ␳ ⫽ .238, P ⫽ .01).

C OMMENT Nearly all obstetrics and gynecology residency programs surveyed require residents to complete a research project to graduate, thereby, acknowledging the importance of research education. Yet, despite the overwhelming number with a research requirement, there is significant variation in the educational techniques and allocation of resources for research education. Less than half of programs had a formal research curriculum, courses in biostatistics and epidemiology, or access to statistical software for data entry and management. The discrepancy between the perceived value of resident research and the lack of time or resources is concerning and consistent with other reports that have cited lack of infrastruc532.e3

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TABLE 4

Program directors responses to how well prepared residents are upon graduation % Program directors

Interpret the published literature

Very prepared

Prepared

45%

52%

Unprepared 2%

Very unprepared 1%

..............................................................................................................................................................................................................................................

Design a research project

8%

74%

15%

3%

10%

76%

14%

0

4%

64%

30%

2%

15%

72%

11%

2%

..............................................................................................................................................................................................................................................

Prepare an abstract

..............................................................................................................................................................................................................................................

Prepare an IRB submission

..............................................................................................................................................................................................................................................

Analyze and interpret results

..............................................................................................................................................................................................................................................

Write a research protocol

2%

70%

26%

2%

Write a manuscript

4%

55%

39%

1%

..............................................................................................................................................................................................................................................

ture, curricular time, and financial support as barriers to resident research.3,7,10,11 By only surveying residency program directors attending the Association of Professors of Gynecology and Obstetrics annual meeting, our data may overrepresent programs that emphasize research and scholarship. Consequently, educational opportunities and resources dedicated to research may be higher in this cohort. Published data from other medical subspecialties describe several curricular opportunities that are consistently offered by successful resident research programs. Most productive and effective resident research programs have the following in common: (1) They appoint an official Director of Resident Research, who is responsible for providing structure and accountability to residents and faculty mentors; (2) they offer a formal research curriculum designed to teach the essential aspects of study design and analysis; (3) they provide dedicated time in each resident’s schedule to conduct their research; (4) they provide funding and opportunities for residents to present their research; and (5) they employ enthusiastic mentors to engage, encourage, and guide residents with their research projects.10-12 Internal medicine residents who successfully completed a research project and presented at the American College of Physician’s scientific meeting had similar recommendations for facilitating resident scholarly activity: (1) protected time, (2) availability of technical resources, (3) established

American Journal of Obstetrics & Gynecology NOVEMBER 2007

research curriculum, (4) good mentors, (5) funding to present research, and (6) encouragement.13 Although only a third of obstetric and gynecology residency programs provide specified rotations to do research, protected research time was associated with continuing to do research after graduation and the ability to write a research protocol. These data are consistent with reports from emergency medicine,14 internal medicine,15 family practice,16 and anesthesiology9; all of whom showed a positive association between protected research time and successful resident research. In another study, 1 program identified 4 barriers to resident research, including lack of a research elective, director, funding, and requirement.17 The program then implemented all 4 perceived barriers and demonstrated a significant increase in resident research activity via presentations and publications. However, protected research time was the least effective of the 4 strategies, whereas appointment of a research director was highly effective. Several studies have demonstrated appointment of a resident research director with increased resident research activity (publications and presentations).17,18 Thirty-eight percent of internal medicine programs have a research director, who devotes approximately 10% of their time teaching, mentoring, and supervising research activities.11,18 In our survey, a formal research curriculum and doing research after graduation were associated with preparedness to in-

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www.AJOG.org terpret the published literature, as well as write a research protocol and manuscript. This suggests that establishing a formal resident research curriculum will accomplish the obstetric and gynecology program directors’ number 1 goal for residents, ie, to interpret the published literature. However, a formal curriculum may have also increased the number of obstetrician-gynecologists who remain in academic medicine and continue to do research. Additional benefits of a structured research curriculum include increased faculty scholarly activities, another ACGME requirement (Table 1). One program demonstrated a significant increase in faculty publications; faculty coauthors rose from 0-24 in 6 years after implementing a structured research program with a formal curriculum.17 Although our study did not query program directors regarding whether they had a dedicated resident research director or how funding was allocated for research projects and presentations, other disciplines have consistently shown these to increase productivity. Consistent with prior reports, a formal research curriculum and protected research time are associated with not only future research efforts, but also enhanced ability to interpret and use the published literature, which is essential for all clinicians. Our data suggest a formal research program, including a research curriculum, may benefit obstetrician-gynecologists regardless of whether they intend to pursue academic medicine or private

practice. A recent review of published resident research curricula identified 41 articles describing resident research curricula,19 although few described all the necessary steps for curricular development, ie, needs assessment, clearly defined learning objectives, the curriculum, assessment of the program, and assessment of the learners. Future educational efforts that are directed at development and validation of a research program for obstetrics and gynecology residents are strongly encouraged. f REFERENCES 1. Accreditation Council for Graduate Medical Education. Common residency program training requirements. Chicago: ACGME; 2006. 2. Beasley BW, Scrase DR, Schultz HJ. Determining the predictors of internal medicine residency accreditation: what they do (not what they say). Acad Med 2002;77:238-46. 3. Liese BS, Johnson CA, Govaker DA, O’Dell ML. Increasing research productivity in a university-based residency program: a case study. Kans Med 1988;89:143-7. 4. Abramson M. Improving resident education: what does resident research really have to offer? Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol 1977;84:984-5. 5. Turnberg LA. The place of research in the training of NHS consultant physicians. J R Coll Physicians Lond 1993;27:403-4. 6. Neale AV. A national survey of research requirements for family practice residents and faculty. Fam Med 2002;34:262-7. 7. Hershberg RI, Harper D, Leichner P. Research in psychiatry: residents’ attitudes and use. J Med Educ 1980;55:540-1. 8. Wilson JL, Redman RW. A program for teaching research in a family practice residency. J Fam Pract 1980;10:729-30.

9. Silcox LC, Ashbury TL, VanDenKerkhof EG, Milne B. Residents’and program directors’ attitudes toward research during anesthesiology training: a Canadian perspective. Anesth Analg 2006;102:859-64. 10. Hayward RA, Taweel F. Data and the internal medicine houseofficer: alumni’s views of the educational value of a residency program’s research requirement. J Gen Intern Med 1993;8:140-2. 11. Alguire PC, Anderson WA, Albrecht RR, Poland GA. Resident research in internal medicine training programs [comment]. Ann Intern Med 1996;124:321-8. 12. Schultz HJ. Research during internal medicine residency training: meeting the challenge of the Residency Review Committee [comment]. Ann Intern Med 1996;124:340-2. 13. Rivera JA, Levine RB, Wright SM. Completing a scholarly project during residency training: perspectives of residents who have been successful. J Gen Intern Med 2005;20:366-9. 14. Levitt MA, Terregino CA, Lopez BL, Celi C. Factors affecting research directors’ and residents’ research experience and productivity in emergency medicine training programs. Acad Emerg Med 1999;6:356-9. 15. Hepburn MJ, Battafarano DF, Enzenauer RJ, et al. Increasing resident research in a military internal medicine program. Mil Med 2003;168:341-5. 16. DeHaven MJ, Wilson GR, O’Connor-Kettlestrings P. Creating a research culture: what we can learn from residencies that are successful in research. Fam Med 1998;30:501-7. 17. Fischer JL, Cation LJ. Impact of a residency research program on research activity, faculty involvement, and institutional cost. Teach Learn Med 2005;17:159-65. 18. Durning SJ, Cation LJ, Ender PT, GutierrezNunez JJ. A resident research director can improve internal medicine resident research productivity. Teach Learn Med 2004;16:279-83. 19. Hebert RS, Levine RB, Smith CG, Wright SM. A systematic review of resident research curricula. Acad Med 2003;78:61-8.

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