Journal of Surgical Research 153, 148 –151 (2009) doi:10.1016/j.jss.2008.03.029
ASSOCIATION FOR ACADEMIC SURGERY, 2008 Surgical Resident Research Productivity Over 16 Years Steven T. Elliott, M.D., and Eugene S. Lee, M.D., Ph.D.1 Department of Surgery, University of California, Davis, Sacramento, California Submitted for publication January 7, 2008
Background. General surgery training has changed over the past decade due to the 80-hour work week and increasing demands on the surgery faculty to generate clinical revenue with ever decreasing reimbursements. The purpose of this study was to evaluate surgery resident productivity over the years and the surgery resident’s contribution to clinical and basic research literature. Method. A PubMed literature search of all graduating chief residents (n ⴝ 95) over a 16-y period from a single university-based general surgery program were evaluated. Number and types of publications (clinical paper versus basic science paper) were analyzed for each resident. A cohort of residents graduating from the years 1990 to 1996 (n ⴝ 42) were deemed the early group and a cohort of residents graduating from the years 1999 to 2005 (n ⴝ 41) were deemed the late group. Residents graduating in 1997 and 1998 were deemed the washout group. Results. From 1990 to 2005, there were 95 graduates with 204 published articles. Resident research time ranged from 0 to 2 y, with most residents spending 1 y of research time. In the early group, residents averaged 2.0 ⴞ 0.4 papers versus the late group where each resident published 2.6 ⴞ 0.5 papers (P ⴝ NS). In the early group, 24.4% of the papers were basic science in nature as opposed to the late group where 27.7% of the papers were with a basic science topic (P ⴝ NS, 2 analysis). Conclusions. Resident research productivity at a single university-based program with an elective research time does not appear to be deteriorating over time. A majority of research performed by residents is clinically oriented; however. basic science research does not appear to be decreasing. Careful scrutiny to resident research productivity is needed to ensure productive future academic surgeons. Published by Elsevier Inc. All rights reserved. 1
To whom correspondence and reprint requests should be addressed at Department of Surgery, University of California, Davis, 4860 Y Street, Suite 3400, Sacramento, CA 95817. E-mail: EugeneS.Lee@ ucdmc.ucdavis.edu.
Key Words: general surgery; residency; resident research. INTRODUCTION
Surgical training is evolving from the Halstedian system of the 20th century to meet the demands of the 21st century. The general surgery residency program of this century has multiple competing forces trying to balance distinct and differing priorities. This includes the goals of newly graduated physicians, the professional expectations of an established surgical society, and the public’s expectations of safe and exceptional surgical care. Work hour reforms, financial costs of training, the rise of super-subspecialization as well as the changing demographics of the surgical residents all impact this metamorphosis. With the changing terrain of general surgery residency, research may have a diminished emphasis in the surgical training program of today. Resident research is an important aspect of general surgery training. General surgeons who have participated in research during their residency have made substantial contributions to the medical community. Norman Shumway, Edward Mason, and M. Judah Folkman all participated in research during their residencies and continued on to develop techniques for heart transplantation, bariatric surgery, and revolutionary cancer therapy, respectively. The importance of laboratory research time should not be underestimated, as this may stimulate surgical residents to pursue important new discoveries in surgical science [1]. A substantial number of surgical residents leave fulltime clinical rotations to participate in 1- to 3 y of research during the middle of their training program to conduct research. However, previous investigations have shown the importance of the resident research experience to conduct research participation after graduation from surgical residency [2, 3]. Robertson and colleagues published a single institution survey of graduates regarding the outcome of doing a research
148 0022-4804/09 $36.00 Published by Elsevier Inc. All rights reserved.
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ELLIOTT AND LEE: RESIDENT RESEARCH PRODUCTIVITY
TABLE 1 A Comparison of the Early and Late Periods*
Early 90–96 Late 99–05 P value
N
Total papers
Clinical papers
Basic science
Papers/resident
Clinical/resident
Basic science/resident
42 41 —
85 108 —
64 78 —
21 30 —
2.0 ⫾ 0.4 2.6 ⫾ 0.5 NS
2.1 1.9 NS
0.9 0.7 NS
* The graduating classes of 1997 and 1998 were not included in the table for analysis.
fellowship during general surgery residency. The authors concluded that post-training funding was related to productivity and receiving grant money during residency [2]. To date, very little data exist regarding the resident research experience and productivity during these changing times. Our goal was to objectively address the resident research productivity at our single university hospital to see if a trend was present over the past 16 y. With the changing environment of surgical education, the authors hypothesized that resident productivity would be decreasing. In this study, we evaluated surgery resident productivity over the years and the surgical resident contribution to the clinical and basic research literature. METHODS All graduates (n ⫽ 95) from the general surgery residency program at the University of California, Davis from 1990 to 2005 were included in this study. This is an academic based general surgery residency program that is 5 y in length with an elective resident research year option. This study met the University of California, Davis Institutional Review Board’s exemption criteria, given that all information was already published and available as public domain. A PubMed literature search was performed for each general surgery graduate. Each search involved the last name with first and middle initial of the graduate. Each PubMed search had a timeperiod limitation of 9 y. Nine years was selected to include work performed during the entire period of residency (intern through chief) and the protected research years (7 y) and to accommodate for publication lag time after graduation. Citations were analyzed individually to verify the appropriate resident’s authorship for a publication. Verification was based on the publishing institution information and cross-referencing senior authors as faculty members at the University of California, Davis. The results of each search were analyzed regarding the number and types of publications. Type of publication for each resident was assessed to be either clinically based (patient-oriented) or basic science oriented (bench work). Information available from the department alumni management provided analysis of positions immediately after general surgery residency to determine if fellowship of career positions were obtained. Individual resident demographics regarding lab time and length of protected lab time were also assessed. A cohort of residents graduating from the years 1990 to 1996 (n ⫽ 42) were deemed the early group and a cohort of residents graduating from the years 1999 to 2005 (n ⫽ 41) were deemed the late group. Residents graduating in the class years 1997 and 1998 were considered the washout group. This group was selected as the washout group for statistical analysis based on departmental changes including a new chairman and a transition from required research to a voluntary system.
A 2 analysis was performed to compare groups and a P-value ⬍ 0.05 was considered significant.
RESULTS
From 1990 to 2005, there were 95 graduates with 204 published articles. Resident research time ranged from 0 to 2 y, with most residents spending 1 y of research time. In the early group, residents averaged 2.0 ⫾ 0.4 papers as opposed to the late group where each resident published 2.6 ⫾ 0.5 papers (P ⫽ NS). The resident classes of 1997 and 1998 were excluded. In these classes, there were 12 residents with a total of 10 publications in those years. In the early group, 24.4% (21/86) of the papers were basic science in nature as opposed to the late group where 27.7% (30/108) of the papers were with a basic science topic (P ⫽ NS, 2 analysis), see Table 1. There is variability between resident classes by year without any major distinct patterns of publication productivity over the years (Fig. 1). Also, there appears to be a trend in more recent years in higher publication totals as graduating chief residents, with more residents writing a greater proportion of the papers in the basic science area (Fig. 2). Demographic analysis was performed to assess graduates who continued on to fellowship training. Fortysix of 95 (48%) continued on to fellowship. The early cohort 14/42 (33%) of graduates continued on to fellow-
FIG. 1. A bar graph depicting the average publications per resident for the graduating class based upon year.
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FIG. 2. A bar graph of total publications for the entire class, with solid white depicting clinical papers and the shaded bar depicting the proportion of basic science papers.
ship. The late cohort 26/41 (65%) continued on to fellowship. The washout group 6/12 (50%) residents sought fellowship training. A subset analysis of the publications from graduating residents who continued on to fellowship was performed. The early cohort 44.1% (38/86) of publications were contributed by residents continuing on to fellowship. The late cohort 88% (95/108) were contributed by residents continuing on to fellowship. Assessment of unpublished residents who continued on to fellowship showed that 21% (3/14) of the early cohort did not have publications during their residency tenure while in the late cohort 23% (6/26) did not publish. The washout group 8/10 articles were from residents who continued on to fellowship and 2/6 residents continued on to fellowship without publications. DISCUSSION
Traditionally, major academic surgical programs have mandated their surgery residents spend 1 to 3 y of structured laboratory research in addition to their 5-y clinical general surgery training. The mandated research time comes at a cost to the surgical resident but also to the supporting departments to conduct this as an important aspect in the training program. Robertson and colleagues estimate 20% of all surgery residents have historically entered the laboratory each year [2]. However, surgery training programs have gone through several transitions, including the adaptation of new work hour rules [4], changing patterns of resident operative experiences [5], as well as decreasing faculty publication rates over the years, presumably due to increasing demands of clinical activity with decreasing reimbursements [6]. More recently, rising educational debt also appears to be an important factor in resident choices to pursue a career in academic surgery.
Ko and colleagues conclude that resident research time is critical to the development of producing academic surgeons [1]. However, beyond that, Lessin and colleagues report that beyond resident research time, a resident’s ability to publish during training correlated well with continued publications as an attending physician [6]. Given this, Robertson and colleagues had evaluated their resident productivity in the ability of their alumni from the Washington University in St. Louis to garner extramural support. Indeed, they found that funding after residency was directly related to productivity of research publications. However, the authors caution against the fact that there was no control arm and that residents may self-select themselves toward academics within the Washington University program [2]. In this study, the University of California, Davis is an academic program with an elective 1 to 2 y of laboratory research with many of the residents electing to spend 1 y. Since the majority of residents are less decided about their commitment to an academic practice, resident productivity may be more influenced by the vagaries of departmental funding and research opportunities offered by the faculty compared with the Washington University residents. Hence, faculty productivity and oversight may become an issue. The University of California, Davis, Department of Surgery has changed during this 16-y time period with the appointment of a new chairman (1995) and 3 program directors (tenures as follows: 1989 –1998, 1999 – 2003, and 2003 to current.) Abolishment of required research time occurred between the early and late cohort. Also, the university has benefited with an increase in faculty membership over time and may reflect the growing trend in our resident productivity. Hence, faculty oversight and productivity may be an issue. Another significant factor is resource availability for research. Residents are able to travel to participate in
ELLIOTT AND LEE: RESIDENT RESEARCH PRODUCTIVITY
research off campus, but local resources would obviously facilitate easier access to resident participation. Over the 16-y time period, our department has increased local resources for research participation. Examples include the completion of a Shriner’s hospital and accessibility to productive burn and wound care labs in 1997, and an additional active surgical oncology lab in 1998. Resource availability may affect our single institution research productivity trends. Our institution also mirrors national trends with an increased movement toward further specialization with fellowship training. A larger proportion of residents are entering fellowship, 33% versus 65% in the early and late cohorts, respectively. Within these subgroups, there is an increase in publications (44% versus 88%) contributed by fellowship bound residents. This trend could be attributed to the increasing competition within the subspecialty applicant arena. Further conclusions of publications as a means or qualification to reach fellowship in our study could not be assessed based on our analysis, which did not include analysis of the residents who did not continue on to fellowship (published or not) but had applied or interviewed for fellowship positions. With increasing economic and time constraints, the formal resident research experience is being evaluated [2, 3, 7, 8]. In several of the published reports, the resident research experience clearly appears to be a valuable training paradigm, but metrics of success are just now being evaluated. Many of the publications are based upon survey results and opinions of attending surgeons and academic surgical society members. This publication is an attempt at evaluating a more objective metrics of publications in peer-reviewed journals. The weakness of this analysis is that consideration is not given to impact factor in publication and the nature of the publication, such as a case report versus the results of a randomized trial. In evaluating the results, the authors initially believed that resident productivity would have demonstrated a trend toward fewer papers and much fewer basic science publications. However, this has not been
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found to be true. In fact, there appears to be tremendous variability, with an increasing trend to increased productivity over the past few years. No significant decrease in the proportion of basic science papers published has been found. In conclusion, general surgery residency is currently in a state of flux regarding educational priorities and finite resources. Work hour reform, resident operative experience, duration of resident training, and patient care continue to be on the forefront of surgical education [5]. Resident research productivity at a single university-based program with an elective 1- to 2-y research time does not appear to be deteriorating over time. Residents who continue on to fellowship training appear more productive with more publications (clinical or basic science). Careful scrutiny to resident research productivity is needed to ensure productive academic surgeons in the future. REFERENCES 1.
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Ko CY, Whang EE, Longmire WP, et al. Improving the surgeon’s participation in research: Is it a problem of training or priority? J Surg Res 2000;91:5. Robertson CM, Klingensmith ME, Coopersmith CM. Long-term outcomes of performing a postdoctoral research fellowship during general surgery residency. Ann Surg 2007;245:516. Whang EE, Perez A, Ito H, et al. Work hours reform: Perceptions and desires of contemporary surgical residents. J Am Coll Surg 2003;197:624. Parsa CJ, Organ CH Jr., Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg 2000; 135:570;Discussion 573. Galt SW, Kraiss LW, Sarfati MR. Has the changing nature of vascular surgery adversely affected scholarly activity? J Vasc Surg 2003;38:1. Lessin MS, Klein MD. Does research during general surgery residency correlate with academic pursuits after pediatric surgery residency? J Pediatr Surg 1995;30:1310.
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Schneider JR, Coyle JJ, Ryan ER, et al. Implementation and evaluation of a new surgical residency model. J Am Coll Surg 2007;205:393.