Stewart RD, Doyle J, Lollis SS, Stone MD. Surgical Resident Research in New England. Arch Surg. 2000;135(4):439-444. doi:10.1001/archsurg.135.4.439
This study sought to determine the attitudes of general surgery residents in New England toward research and the factors that affect their research participation and productivity.
Eighteen of the 20 general surgery residency programs in New England.
Four hundred fifty-nine surgical residents taking the American Board of Surgery In-Training Examination in 1999.
Main Outcome Measures
Rationale for and amount of time spent in research and the number of publications.
A majority of residents (61%) participated in research. Rationales for research participation included initiating an academic career (82%) and enhancing fellowship application prospects (83%). Personal debt was substantial, but had little influence on decisions regarding research. Gender was not a factor in the decision to participate in research, although women were more likely to cite a break from residency as a positive influence in their decision for doing research. Residents from larger programs (>25 residents) were more likely to participate in research, spend more time in research, and to publish an article than those from programs with fewer than 25 residents.
Most surgical residents in New England plan to or participate in research and publish their work. Significant differences in the type, duration, and productivity of research exist between larger and smaller programs, and may reflect differing priorities among residents, or differences in the variety of research opportunities available.
RESEARCH PERFORMED by surgical residents during residency is considered to be an initial step on the road to a career as an academic surgeon. The benefits of time engaged in research are myriad. During this time, residents learn and gain experience in the generation of research ideas, the development of hypotheses, and the use of scientific methods, as well as honing verbal and written communication skills—all requisite skills for a successful career. At the same time, they develop critical thinking skills and enhance their ability to evaluate the scientific literature, as well as learning the difficulties of carrying out a successful research project. They also develop a broader perspective on clinical questions. In our experience, residents return to surgical training after a research period with notably greater maturity as surgeons. Evidence of research during residency is often considered a prerequisite for acceptance into surgical subspecialty fellowship programs. The research period may allow residents who are uncertain of their desire for an academic career to make informed decisions in this regard.
Many surgical residents participate in original investigation during their residency period. To date, however, only a few studies have looked at the attitudes and outcomes of surgical research during residency. Souba et al1 found that surgical residents, more so than their chairs, felt that basic science research was essential for an academic career; however, their motivation for entering the laboratory was a genuine interest in research. Lessin and Klein2 examined the academic credentials of pediatric surgeons and compared their record of laboratory research during general surgery training with their academic pursuits and productivity after specialty training, and found no correlation. Dunn et al3 showed a positive correlation between length of research time during training and academic careers of graduates in a single program. These select groups, however, do not necessarily reflect the attitudes, experience, or productivity of general surgical residents in research.
Stress levels in training programs and among residents are higher than ever before. Changes in the health care system, including reduced hospital and departmental revenues, increased personal debt on the part of residents, and a greater desire for a controllable lifestyle among medical school graduates, have all occurred over the last 10 to 15 years. In today's milieu of decreased funding for graduate medical education, the cost of providing or covering residents' research periods are straining the already constrained budgets of academic medical centers. At the same time, with unprecedented debt levels, residents may feel increased pressure to complete their clinical training in shorter time. For female residents, this pressure may be compounded by family planning concerns.4 Given these pressures, answers to the questions of why residents choose to pursue or to opt out of research during their clinical training programs are increasingly important.
We hypothesized that changes in program funding, resident indebtedness, and stress may have a negative impact on residents' interest and ability to engage in research during residency, and sought to compare attitudes of those who select research with those who do not.
As part of a multistage assessment of research during surgical residency, we surveyed residents in New England programs to assess current attitudes toward and performance of research. An initial survey was piloted with a sample of residents in our program. Revised surveys were distributed to all 20 general surgery residency programs in New England. Residents were asked by their program directors to complete the questionnaire after administration of the American Board of Surgery In-Training Examination (ABSITE) in January 1999. Instructions asked for voluntary and anonymous participation of residents sitting for the examination. A return envelope was included, but no identification of individual programs was made.
The survey asked residents for demographic information (age, sex, postgraduate year (PGY) level, other advanced degrees held, marital status, number of children, and indebtedness level) and their involvement in research. Those who were doing or planned to do research were asked about the nature of the research (basic vs clinical), the timing, and the outcome in terms of the number of publications, and were asked to rate, on a 3-point scale (1, no; 2, some; and 3, significant influence), 6 factors that may have influenced their decision to do research. Those who had decided against a research elective were asked to rate, again on the same 3-point scale, 7 factors that may have influenced that decision.
Data from returned questionnaires was entered into a Microsoft Access database (Microsoft Inc, Redmond, Wash). A numeric code was assigned to all questionnaires from a single program, based on order of receipt. As a surrogate for university-based, academic programs, programs with more than 25 residents were categorized as "large." Conversely, programs with fewer than 25 residents were categorized as "small."
Responses were analyzed by item across all programs, as well as by size of the program. Responses were also analyzed by resident sex, parenthood status, and level of indebtedness. For purposes of analysis, productivity was defined as the publication of at least 1 article per year of research; those individuals with less than 1 year of research experience were excluded. We used the χ2 and Fisher exact tests to determine, as appropriate, association for all responses. Significance was determined at a 2-sided level of .05.
Eighteen (90%) of the 20 residency programs participated. Overall, 459 (79%) of the 584 surgical residents taking the ABSITE in New England responded: 332 (73%) of 456 respondents were male; 124 (27%) were female; and 3 did not indicate sex. Sixty-nine (15%) of the respondents possessed an advanced degree in addition to their medical degree. Respondents ranged in age from 24 to 46 years, with a mean ± SD age of 30.1 ± 3.4 years (Table 1).
Of the respondents, 279 residents (61%) either have done or are planning to do research (34% plan or are currently engaged in research and 27% have completed research). The majority (56%) of those who elect to do research do so for 2 years or more, and 84% of those who engage in research schedule their electives somewhere between the PGY-2 and PGY-4 years in training: 46% schedule them between the PGY-2 and PGY-3 years and 38% between PGY-3 and PGY-4. Of those who have completed their electives, most (69%) have published at least 1 article; 18% published 3 or more (Table 2).
Among residents completing or planning research electives, the factor credited with the most significant influence in the decision was "to initiate an academic career" (51%); an additional 31% of residents in research cited this as a factor of some influence. A research period's perceived ability to help the resident obtain a desirable fellowship followed closely in influence, with 46% of those in or planning research citing this as a significant influence, and another 37% citing it as a factor of some influence. Finding out whether they liked research was a significant influence for 19%; an additional 42% said it had some influence on their decision to engage in research. Sixty-one percent of residents said the desire to take a break from residency exerted some influence on their decision to do research, with 20% of residents in research citing this as a significant influence and 41% citing it as a factor of some influence. Of less influence in residents' decision-making process was the fact that research was mandatory in respondents' programs: 18% cited this as a significant influence and 28% as of some influence. The opportunity to earn money moonlighting was also less influential: only 7% cited this as a significant influence and 20% cited it as a factor of some influence (Table 3).
Among residents who neither had done nor plan to do research, lack of interest seems to be the most influential factor, with 64% of nonresearch residents saying it was of significant (25%) or some (39%) influence. Having done research before residency was cited by 54% of nonresearch residents as exerting either significant (25%) or some (29%) influence on the decision not to pursue research during residency. Forty-five percent cited their plan to do research during fellowship as influencing their decision not do research during residency: 22% said it had a significant influence and 23% said it had some. Lack of time for research was a significant influence for 19% of these residents, and had some influence on another 25%. "Family conflict" was cited by 37% of residents as a factor weighing in on their decision not to do research during residency: 9% said it was a significant influence, and another 28% said it had some influence. Nearly a quarter (23%) of these residents said that lack of opportunity in their program was a factor influencing their decision: 6% said it had significant influence and 17% said it had some. Those with advanced degrees were no more or less likely to engage in research (P=.40) (Table 4).
Although the majority of residents (51%) in the study had $50 000 or more in personal debt, indebtedness seems to have no influence in either prodding residents into or out of research, with residents who do research and those who do not found in equal proportions at each level of indebtedness (P=.80).
Sex seems to play little or no role in the research paths taken by surgical residents in New England, with 55% of women and 63% of men planning or participating in research (P=.10). There were no significant sex differences in either the type of research (64% of women vs 58% of men chose basic science and 30% of women vs 29% of men chose clinical research, respectively [P=.40]), or the length or timing of research.
Surgical residents of both sexes seem to share similar rationales for pursuing research, with the exception of the desire to take a break from residency: 79% of women and only 55% of men (P=.001) cited this as a factor with either some or significant influence. Among those residents who elect against doing research, significantly more women than men cite lack of interest as a factor of some or significant influence (35% of women vs 20% of men said it was a significant influence [P=.03]). Female and male surgical residents who do research also have similar productivity: 69% of women and 71% of men who have completed a research elective have 1 or more publications (P=.40).
There was no association between parenthood and research: 58% of surgical residents with children have done or plan to do research, compared with 61% of residents who have no children (P=.60).
Ten (56%) of the 18 responding programs had more than 25 residents (large programs) and 8 (44%) had fewer than 25 residents (small programs) (Table 2). Significantly more residents have done or plan to do research in larger programs than in smaller programs. Residents in larger programs are also more likely to choose basic science research, while residents in smaller programs are more likely to choose clinical research.
Residents in larger programs also planned or spent longer periods in research, with the majority (64%) choosing 2 years or more; conversely, the majority of residents (59%) in small programs plan or spend 6 months or less (Table 2).
Reasons for or against engaging in research during residency differ by the size of a resident's program, with 68% of those choosing to do research in larger programs citing the need for a break from clinical work as a deciding factor (22% cited this as a significant influence; 46%, some influence), whereas only 23% of those in smaller programs cited that as a factor (P=.001). Additionally, 86% of those in larger programs vs 70% in smaller programs cited the benefits of research experience in helping them to obtain a fellowship (P=.02). Conversely, 38% of those residents in smaller programs who have chosen not to engage in research cited lack of availability in their programs as a factor of some (23%) or significant (15%) influence in their decision (P=.001).
Among residents who had completed their research period, those in larger programs were more likely to have published at least one article (50% vs 26%) (P=.03). When productivity was defined more specifically as one publication per year of research, there was no difference in the productivity of men (54%) and women (48%) (P=.90), nor between those with a medical degree (56%) and those with an advanced degree (52%) (P=.90). Those residents who pursued research believing that it would enhance their fellowship opportunities were neither more nor less productive than their peers (50% vs 48%) (P=.70).
Interest and participation in research is strong among residents in New England surgical training programs. The majority of residents have completed or are planning research, and most have committed or plan significant time—2 years or more—to this effort.
Most residents are productive, with more than two thirds publishing at least 1 article. The fact that 31% of residents who have completed research have published nothing to date, however, seems excessive. It may be that some still have work in progress, or that a subset of residents are missing a key part of the research experience—that the mentoring relationship has not been successful for these residents.
Most residents choose research for appropriate reasons: to initiate an academic career and/or to determine whether they have an appetite or aptitude for research. Most influential in the decision to pursue research was a sense that a research background would contribute positively in the fellowship application process, reflecting the view that fellowship programs select applicants more likely to be academic surgeons. The likelihood of performing additional research during fellowship was not a dissuasion from research during general surgery residency. Most residents do not feel compelled by their programs to take research time.
Among those residents not planning research work, lack of interest was the most common rationale. More than half had engaged in research prior to residency, suggesting that their prior research experience was sufficient for career goals, or possibly that it was an unsatisfactory experience.
Overall, only 6% felt that lack of research opportunity was a significantly negative influence on their decision against research; but more than a third of residents in small programs indicated this was an influence on their decision not to engage in research. It is not clear from this study whether this difference between small and large program residents is a result of differences purely in opportunity or resident self-selection—that is, residents select programs that reflect their level of interest in research and vice versa. Whether these residents would do research, and what type, if available, is unanswered by this study. Significant differences in the type and duration of research between larger and smaller programs may reflect differences in the availability of basic science research mentors and opportunities. Program directors should discuss this issue with residents in career planning sessions.
For small programs, or for those programs in which interest and performance in research varies from one PGY cohort to the next, finding residents to replace those who depart for research may be difficult or impossible. Faculty with available research positions should be aware that a potential source of trainees may exist, untapped, in smaller New England programs. One way to maximize resident opportunity and satisfaction may be establishment of a regional clearinghouse of research opportunities. Such a system would provide regionwide dissemination of information regarding available research opportunities, and allow matching of residents with research opportunities in their area of interest.
Personal debt has previously been identified as a major concern among New England surgical residents.4 Although 51% of our respondents indicated personal debt exceeding $50 000, indebtedness seems to have no influence on the decision of whether to engage in research: few surgical residents in New England are dissuaded from spending time in research because of the pressure to finish training and repay their outstanding debt, nor do they consider the opportunity to earn money moonlighting as a significant reason to take research time.
It is not clear from these results how to interpret the finding that taking a break from residency is more important to residents from large programs. It may well be that the residents in large programs feel more isolated or anonymous, with less support than that in a smaller, more tightly knit, resident cohort. It may also be that resident work hours, not addressed in this survey, may be more taxing in large programs. Program directors should be aware of this rationale among residents and should counsel residents not to select a research elective solely for this purpose.
No differences were apparent between male and female surgical residents in terms of the proportions who choose to pursue research during residency, the type of research they choose to engage in, or productivity. Although twice as many male as female residents had children, parenthood per se was not a factor in whether residents choose research. Women are significantly more likely than men to cite seeking a break from residency as a rationale for research. Since having children during residency and postponing family plans has been found to be significant concerns of female surgical residents, one might anticipate that women would desire completion of surgical training without additional time being taken for research. This runs counter to our finding in this study that taking a research period to get a break from residency was a prominent rationale for female residents. Program directors should be aware of this dichotomy, as it may contribute to even greater stress among female residents. The finding that lack of interest in research is a significantly more influential factor among women than men in the decision not to pursue research may reflect women's perception of a "glass ceiling" in academic medicine.
Most surgical residents in New England plan or perform some research and publish their work. Primary among their reasons for doing so is an intellectual interest in research. Results of the current study confirm the conventional wisdom that residents who choose to do research while in clinical training intend to pursue academic careers; in addition, they believe that research experience in training provides them an advantage in obtaining fellowships.
Significant differences in the type and duration of research exist between larger and smaller programs, and may reflect differing priorities among residents, as well as differences in the extent of research opportunities available to them. Further study is needed to determine whether resident aspirations for an academic career are borne out in the acquisition of fellowships, continued research productivity, and faculty appointment.
This study was supported in part by a grant from the Harvard Medical School and Beth Israel Deaconess Mount Auburn Institute for Education and Research, Boston, Mass (Drs Stewart and Stone and Ms Doyle).
Presented at the 80th Annual Meeting of the New England Surgical Society, Newport, RI, September 25, 1999.
Corresponding author: Michael D. Stone, MD, Department of Surgery, Harvard Medical School and the Beth Israel Deaconess Medical Center, 110 Francis St, Suite 3A, Boston, MA 02215 (e-mail: firstname.lastname@example.org).
John A. Mannick, MD, Boston, Mass: Dr Stewart and his associates have done a real New England survey of the participation of surgical residents in research. They were fortunate to receive the cooperation of almost all of the surgical residency programs in our area. The response from the residents they pooled was absolutely outstanding—about 80% of them responded. This in itself is a real accomplishment, considering the harried life most residents lead.
The investigators divided the residencies, as you have seen, into 2 categories: those with more than 25 residents and those with fewer than 25 residents. They found that the participation in research during residency was greater in the larger programs, which is perhaps not surprising, although the percentages were not vastly different: 65% participated in the larger programs and 45% in the smaller programs. What was notably different was the period spent in research, with the majority of residents in the larger programs planning to spend 2 years or more in research and only 4% of those in the smaller programs planning such a long time in the laboratory or in clinical research. Residents from smaller programs were also much more likely to be involved in clinical research only. The longer time spent in research by residents from the larger programs was also reflected in a greater number of publications per resident in these programs.
Now I don't really have any argument with the authors' techniques or with their conclusions and I honestly don't have any substantive questions to ask them. What they did not attempt to do was to answer the question of whether participation in research during residency is of real benefit to the subsequent careers of the individuals involved, and I am not sure that is an answer that they were likely to be able to get. I share their prejudice that research during residency is a good thing, even if the individual never intends to make research a part of his or her career after residency. If one has had the opportunity to do a clinical research project, for example, and to write it up for publication, the experience will almost certainly translate into a greater ability to critically evaluate publications in the surgical literature throughout one's career. Whether every resident would benefit from time spent in a basic research laboratory during the course of residency training is, in my mind, far less clear. As the present authors rightly conclude, this probably depends on the individual's professional goals. It also seems very likely that the larger residency programs in our area are more geared to training individuals for positions in academic surgery, where a period of laboratory research during residency may prove invaluable in jump starting an academic career. However, for an individual who is committed to a career in the practice of clinical surgery, I am not at all sure that 2 years in a basic research laboratory during residency is the best use of that individual's time.
What the present authors have documented is that there is considerable variability in the residency programs in our area with regard to resident participation in basic research. Some programs, such as the one I recently directed, which are focused on training people for academic careers lie at one extreme, while those programs dedicated entirely to training expert clinical practitioners lie at the other, with many programs lying somewhere in between.
Dr Stewart: I thank Dr Mannick for those comments. We thank all of the program directors out there who helped with this project; we did get an excellent response. I also agree with you on the fact that the question not answered in this is whether or not research has any bearing on future careers, which is actually the second phase of what this research project is going to be: the first portion asking residents their feelings and research participation and the second looking at practicing surgeons from New England to see what their careers are now and how they will correlate research experience with academic practice in the future.
I also share the concept that writing and publishing an article is a very valuable portion of this experience and should be emphasized.
Finally, I agree with you that the timing of research of 6 months vs 2 years was not meant to indicate that more is better. For some individuals, doing 6 months of research is probably more valuable than doing 2 years if their future career is only to do general practice surgery.
Claude H. Organ, Jr, MD, Oakland, Calif: I rise to discuss this because I will have the opportunity to exercise my discretion when it comes across my desk, but I want to support the concepts being fostered here. I think it has proved its case over the years. The practices that we have today have been dictated by the research of yesterday. Tomorrow will be no different. We have a little different approach. We do not demand that the residents go for the research experience. It's voluntary, not in the voluntary jesuitical sense but truly voluntary. We insist that they have shown evidence in clinical maturation in terms of their decision-making skills, their technical skills and their knowledge base principally around the American Board of Surgery In-Training Examination. If they are doing well in those categories, they may apply for the research experience. This is run by myself and Gerry Peskin, who was formerly a member of the New England Surgical Society. We do not feel that we owe it to them but that they have to earn it. This has proven to work well for us. We consistently have 6 or 8 people working full time in laboratories throughout the country. There are a lot of research positions in training programs that are going unused and we found this to be a very helpful thing in terms of their own knowledge base. We believe they are better clinical surgeons when they return. They certainly have positioned themselves better for fellowships and future residencies. One remarkable experience I just had was with a young man named Brian Cain (finishing with us this year) who was in Alden Harkins' laboratory for 2 years and, incredibly, wrote 48 papers in peer-reviewed journals. I rise in support of this experience. It ought to be voluntary and we should not make this mandatory for these candidates.
Dr Stewart: Thank you, Dr Organ. I've met Dr Cain. He is a very bright young man and has much too big of a curriculum vitae for his level. Do you have any record through this process of selecting residents for research? Do you have a higher rate of residents staying on the academic track following their research?