Portal de Periódicos da CAPES

Scholarship During Residency Training: A Controlled Comparison Study

2011; Elsevier BV; Volume: 124; Issue: 10 Linguagem: Inglês

10.1016/j.amjmed.2011.05.018

1555-7162

Colin P. West, Andrew J. Halvorsen, Furman S. McDonald,

Diversity and Career in Medicine

Scholarship during residency training has important benefits for both learners and faculty. For residents, research experiences promote proficiency in critical appraisal of the literature, a key skill for all physicians, and provide training necessary for successful research activities in fellowship or future academic careers.1Hebert R.S. Levine R.B. Smith C.G. Wright S.M. A systematic review of resident research curricula.Acad Med. 2003; 78: 61-68Crossref PubMed Scopus (85) Google Scholar, 2Levine R.B. Hebert R.S. Wright S.M. Resident research and scholarly activity in internal medicine residency training programs.J Gen Intern Med. 2005; 20: 155-159Crossref PubMed Scopus (85) Google Scholar Research experiences also provide networking opportunities and foster mentoring relationships.1Hebert R.S. Levine R.B. Smith C.G. Wright S.M. A systematic review of resident research curricula.Acad Med. 2003; 78: 61-68Crossref PubMed Scopus (85) Google Scholar, 3Potti A. Mariani P. Saeed M. Smego Jr, R.A. Residents as researchers: expectations, requirements, and productivity.Am J Med. 2003; 115: 510-514Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 4Willett L.L. Paranjape A. Estrada C. Identifying key components for an effective case report poster: an observational study.J Gen Intern Med. 2009; 24: 393-397Crossref PubMed Scopus (11) Google Scholar Research experiences may further satisfy the intellectual curiosity characteristic of many physicians in training and even encourage careers in clinical investigation.5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar, 6Fancher T.L. Wun T. Hotz C.S. Henderson M.C. Jumpstarting academic careers with a novel intern research rotation: the AIMS rotation.Am J Med. 2009; 122: 1061-1066Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 7Oxnard G.R. Zinkus T.M. Bazari H. Wolf M. Integrating research training into residency: tools of human investigation.Acad Med. 2009; 84: 1295-1300Crossref PubMed Scopus (14) Google Scholar For faculty, participation in resident scholarship can result in publications and other activities crucial to academic promotion.8Sridhar A.R. Willett L.L. Castiglioni A. et al.Scholarship opportunities for trainees and clinician educators: learning outcomes from a case report writing workshop.J Gen Intern Med. 2009; 24: 398-401Crossref PubMed Scopus (16) Google Scholar Many faculty also especially prize opportunities to work with inquisitive residents.7Oxnard G.R. Zinkus T.M. Bazari H. Wolf M. Integrating research training into residency: tools of human investigation.Acad Med. 2009; 84: 1295-1300Crossref PubMed Scopus (14) Google ScholarPerspectives Viewpoints•Resident scholarship is a required component of residency training with benefits to both residents and faculty.•Key features of successful resident scholarship programs have been identified, but robust outcomes have seldom been reported.•Mayo Clinic has developed a successful comprehensive research curriculum demonstrating that internal medicine residents can achieve the highest standards of scholarship. •Resident scholarship is a required component of residency training with benefits to both residents and faculty.•Key features of successful resident scholarship programs have been identified, but robust outcomes have seldom been reported.•Mayo Clinic has developed a successful comprehensive research curriculum demonstrating that internal medicine residents can achieve the highest standards of scholarship. In recognition of the importance of resident scholarship, in 1994 the Residency Review Committee for Internal Medicine established that residents must complete “original research, comprehensive case reports, or review of assigned clinical and research topics.”9Common program requirements: general competencies. Accreditation Council for Graduate Medical Education Outcome Project, Chicago, IL2007http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdfGoogle Scholar This language has evolved to the current standard, in which faculty must “establish and maintain an environment of inquiry and scholarship with an active research component” and “encourage and support residents in scholarly activities.”9Common program requirements: general competencies. Accreditation Council for Graduate Medical Education Outcome Project, Chicago, IL2007http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdfGoogle Scholar In addition, the training curriculum “must advance residents' knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.”9Common program requirements: general competencies. Accreditation Council for Graduate Medical Education Outcome Project, Chicago, IL2007http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdfGoogle Scholar Training programs and their parent institutions are expected to “allocate adequate educational resources to facilitate resident involvement in scholarly activities.”9Common program requirements: general competencies. Accreditation Council for Graduate Medical Education Outcome Project, Chicago, IL2007http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdfGoogle Scholar Despite these requirements, many training programs have difficulty developing scholarly opportunities for their learners.10Rivera J.A. Levine R.B. Wright S.M. Completing a scholarly project during residency training: perspectives of residents who have been successful.J Gen Intern Med. 2005; 20: 366-369Crossref PubMed Scopus (104) Google Scholar Numerous barriers to successful implementation of resident scholarship activities have been identified,5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar including lack of faculty mentoring and time,5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar competing resident clinical responsibilities,3Potti A. Mariani P. Saeed M. Smego Jr, R.A. Residents as researchers: expectations, requirements, and productivity.Am J Med. 2003; 115: 510-514Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar, 11Hamann K.L. Fancher T.L. Saint S. Henderson M.C. Clinical research during internal medicine residency: a practical guide.Am J Med. 2006; 119: 277-283Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 12Levine R.B. Hebert R.S. Wright S.M. Factors associated with citation of internal medicine residency programs for lack of scholarly activity.Teach Learn Med. 2005; 17: 328-331Crossref PubMed Scopus (10) Google Scholar and funding limitations.5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar, 10Rivera J.A. Levine R.B. Wright S.M. Completing a scholarly project during residency training: perspectives of residents who have been successful.J Gen Intern Med. 2005; 20: 366-369Crossref PubMed Scopus (104) Google Scholar, 12Levine R.B. Hebert R.S. Wright S.M. Factors associated with citation of internal medicine residency programs for lack of scholarly activity.Teach Learn Med. 2005; 17: 328-331Crossref PubMed Scopus (10) Google Scholar However, since the initial certification requirement was issued there have been several reports of approaches to resident research promotion and common themes have emerged as core elements of a successful residency research program, including exposure to and guidance from mentors, training in research methodology and critical appraisal, protected time for research, an environment supportive of research, an identifiable research director, opportunities to present scholarly activities in peer-reviewed settings, and appropriately focused resident projects with clearly articulated goals, expectations, and timelines.1Hebert R.S. Levine R.B. Smith C.G. Wright S.M. A systematic review of resident research curricula.Acad Med. 2003; 78: 61-68Crossref PubMed Scopus (85) Google Scholar, 5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar, 13Schultz H.J. Research during internal medicine residency training: meeting the challenge of the residency review committee.Ann Intern Med. 1996; 124: 340-342Crossref PubMed Scopus (35) Google Scholar Unfortunately, despite these commonly agreed-on core elements, descriptions of effective programs have typically been compromised by limited objective outcome assessment.1Hebert R.S. Levine R.B. Smith C.G. Wright S.M. A systematic review of resident research curricula.Acad Med. 2003; 78: 61-68Crossref PubMed Scopus (85) Google Scholar At Mayo Clinic, research has been a mandatory part of residency training since 1988,13Schultz H.J. Research during internal medicine residency training: meeting the challenge of the residency review committee.Ann Intern Med. 1996; 124: 340-342Crossref PubMed Scopus (35) Google Scholar even before it became an accreditation requirement. The internal medicine residency research curriculum has been developed over time to meet the key requirements. To assess objective outcomes from this residency scholarship program, we evaluated peer-reviewed publications authored by internal medicine residents beginning training from 2003 to 2006 and completing training from 2006 to 2009 at Mayo Clinic compared with similar residents at other institutions. The resident research curriculum spans the full 3 years of training, beginning with pre-internship orientation. An online research manual expanded from a previously copyrighted and widely distributed format13Schultz H.J. Research during internal medicine residency training: meeting the challenge of the residency review committee.Ann Intern Med. 1996; 124: 340-342Crossref PubMed Scopus (35) Google Scholar (Appendix 1, online) provides core content related to project planning, protocol development, and introductory principles of biostatistics and epidemiology. Additional education resources are available through the Center for Translational Science Activities, the Mayo Graduate School, and semiannual workshops on scientific writing. Protected month-long research electives are available in all years of training. Under the direction of the Associate Program Director for Resident Scholarship acting as the residency research director, residents develop projects with interested mentors across all clinical areas. These connections are facilitated by the faculty education coordinators in each subspecialty, who are most familiar with the work of their colleagues. Approval of research electives requires submission of a proposal, which is reviewed by the residency research director, and a formal approval letter from the mentor. These supporting materials must be submitted at least 2 months before the start of the desired elective month to allow adequate time for critical review and modifications, if necessary. This process is aided by the use of a standardized protocol template (Appendix 2, online). Each research elective is evaluated after its completion by the mentor, and this feedback is shared with the resident. Institutional and residency policies provide travel benefits for dissemination of resident scholarly activities through presentations given at recognized society or association meetings. In addition, training in evidence-based medicine throughout the 3 years of residency is led by the chief medical residents, each of whom pursues advanced training in teaching methods for evidence-based medicine before beginning his/her chief year.14Thomas K.G. Thomas M.R. York E.B. Dupras D.M. Schultz H.J. Kolars J.C. Teaching evidence-based medicine to internal medicine residents: efficacy of conferences versus small-group discussion.Teach Learn Med. 2005; 17: 130-135Crossref PubMed Scopus (20) Google Scholar Residents provide critical review of literature relevant to clinical questions arising for their patients at a weekly conference, the Clinical Decision-Making Journal Club. Residents also receive formal instruction in quality improvement methodology and systems-based practice.15Reed D.A. Wittich C. Drefahl M. McDonald F. A quality improvement curriculum for internal medicine residents. MedEdPORTAL, 2009http://www.mededportal.org/publication/7733Google Scholar For this study, cases were applicants who were matched to our program and began their training between 2003 and 2006, representing 4 separate residency classes completing training from 2006 to 2009. Controls were all applicants on our rank list for these same years who were “ranked-to-match,” that is, were in a position on the rank list such that they would have been matched with Mayo had they ranked our program high enough on their list. This list includes all applicants ranked higher than the lowest ranked applicant who matched with the Mayo Clinic internal medicine training program. The ranked-to-match applicants provide a natural comparison group for assessing scholarship outcomes, because on the basis of their rank list placement they were anticipated to perform at least as well as our matched residents but were matched elsewhere because of personal preference. To objectively quantify the scholarly output of the 2 groups, we examined peer-reviewed articles published between July of each resident's match year and the end of the expected graduation calendar year. Publications were identified using Ovid MEDLINE. We initially searched by author last name, first initial, and middle initial (when available), as provided in the application files. The resulting list of references was then searched manually for full name matches. For references without a listed full first name or where multiple authors were listed under the same name, the institution field was examined for past medical school (from the Electronic Residency Application Service record) or matched residency program (from the National Resident Match Program data). From the list of references attributable to each applicant, we excluded non-journal articles and any publications dated before July 1 of their match year. For each applicant, we recorded the total number of peer-reviewed articles, the number of case reports, the number of first-author publications, and the name of the journal in which each article appeared. Cases and controls were compared on several outcomes, including the number of peer-reviewed articles per applicant, the proportion of applicants with at least 1 publication, and the 2009 journal impact factor of publications.16ISI Web of Knowledge Journal Citation Reports.http://admin-apps.isiknowledge.com/JCR/JCR?PointOfEntry=Home&SID=4CJ7FOdf@M4MNO1BdBHGoogle Scholar Statistical analyses were conducted using SAS version 9.1 (SAS Institute Inc, Cary, NC). The proportions with at least 1 publication were compared using Fisher exact tests. Ordinal outcomes such as number of articles and impact factor were compared using Wilcoxon rank-sum tests. Multivariable analyses of publication counts during residency were performed using logistic and Poisson regression for dichotomous and count data, respectively. Two-tailed statistical significance was set at α=0.05. This study was approved by the Mayo Clinic Institutional Review Board and was not supported by any funding source. The National Resident Matching Program match results for 2003 to 2006 yielded 191 Mayo-matched and 437 ranked-to-match non-Mayo residents. Four applicants were excluded from the study because they were matched to a non-internal medicine training program, and 3 applicants were excluded because they withdrew and were not matched to any training program for the year they applied to Mayo. This comparison left 430 ranked-to-match applicants in the control group for our study. The Mayo cohort included a greater proportion of international medical graduates, although both the Mayo and non-Mayo cohorts reported fewer international medical graduates than are seen nationally.17Brotherton S.E. Etzel S.I. Graduate medical education, 2006-7.JAMA. 2007; 298: 1081-1096Crossref PubMed Scopus (62) Google Scholar The proportion of men in each cohort was similar, and slightly greater than that seen nationally.17Brotherton S.E. Etzel S.I. Graduate medical education, 2006-7.JAMA. 2007; 298: 1081-1096Crossref PubMed Scopus (62) Google Scholar The proportion of residents with peer-reviewed publications before the start of residency was similar for the 2 cohorts (Table 1).Table 1Baseline Characteristics of Matched Mayo Residents and Ranked-to-Match Non-Mayo Residents Beginning Training from 2003 to 2006Baseline CharacteristicMayo (n = 191)Non-Mayo (n = 430)P ValueNo. (%) male126 (66.0)255 (59.3).13No. (%) US medical graduates150 (78.5%)413 (96.0%)<.001No. (%) with publication before start of residency72 (37.7%)150 (34.9%).53USMLE step 1 score⁎Available for residents matching in 2005 and 2006 only (n=311), because electronic application records began in 2005 and prior paper records were not available.231.0233.4.26USMLE step 2 score†Available for residents matching in 2005 and 2006 only (n=241), because electronic application records began in 2005 and prior paper records were not available.234.7239.7.07USMLE=United States Medical Licensing Examination. Available for residents matching in 2005 and 2006 only (n=311), because electronic application records began in 2005 and prior paper records were not available.† Available for residents matching in 2005 and 2006 only (n=241), because electronic application records began in 2005 and prior paper records were not available. Open table in a new tab USMLE=United States Medical Licensing Examination. A summary of the comparative results for the 621 residents in this study is displayed in Table 2. The curriculum was associated with more than 3 times as many peer-reviewed articles per resident (2.1 vs 0.6, P<.001) (Figure 1). This increase was present for both case reports and non-case report journal articles. Approximately twice as many Mayo-matched residents published at least 1 article (66.0% vs 36.0%; P<.001). The median journal impact factor for articles associated with this curriculum also was greater for the Mayo-matched residents (4.6 vs 3.6, P=.003). These results persisted when limiting the comparison cohort to the 139 residents pursuing training at other leading clinical and research institutions, as defined by inclusion on the U.S. News and World Report 2010-11 Best Hospitals Honor Roll.18Best hospitals 2010-11: the honor roll U.S. News and World Report.http://health.usnews.com/health-news/best-hospitals/articles/2010/07/14/best-hospitals-2010-11-the-honor-rollGoogle Scholar Residents training at these 13 peer institutions averaged fewer articles (2.1 vs 0.8, P<.001), and fewer had at least 1 publication during residency (66.0% vs 43.2%, P<.001). In multivariable analyses adjusted for gender, international medical graduate status, and publication before the start of residency, exposure to the Mayo curriculum remained strongly associated both with having at least 1 publication during residency (odds ratio 3.0; 95% confidence interval, 2.1-4.4) and with the number of peer-reviewed publications during residency (2.3 publications greater for the Mayo cohort, 95% confidence interval, 1.9-2.9).Table 2Scholarly Productivity of Matched Mayo Residents and Ranked-to-Match Non-Mayo Residents Completing Training from 2006 to 2009OutcomeMayo (n = 191)Non-Mayo (n = 430)P ValuePeer-reviewed articles, No. (per resident)397 (2.1)276 (0.6)<.001 Case reports, No. (per resident)109 (0.6)56 (0.1)<.001 Non-case reports, No. (per resident)288 (1.5)220 (0.5)<.001 As first author, No. (% of articles)228 (57.4%)132 (47.8%).01At least 1 article, No. (% of residents)126 (66.0%)155 (36.0%)<.0012009 journal impact factor, median4.63.6.003 Open table in a new tab Of note, approximately two thirds of residents had not published a peer-reviewed journal article before the start of residency, regardless of their choice of training program. Only 30.4% of the previously unpublished residents selecting non-Mayo training programs published an article during their training, whereas 58.0% selecting Mayo were published (P<.001). Of the minority of applicants who had published an article before the start of their residency, 46.7% selecting non-Mayo training programs had published during their residency, compared with 79.2% of residents exposed to the Mayo curriculum (P<.001). Women were less likely than men to have published before residency (29.6% vs 39.6%, P=.01), a difference that persisted at non-Mayo programs during residency (24.6% vs 43.9%, P<.001). However, in the Mayo environment there was no difference in publication rates between men and women by the end of residency (63.1% vs 67.5%, P=.63). We report that internal medicine residents can achieve a high standard of scholarship as evidenced by peer-reviewed publication during their training. The scholarship program at the Mayo Clinic internal medicine residency is highly effective, with markedly increased rates of publication for these residents relative to otherwise comparable residents matched at other programs. The elements contributing to the success of this curriculum are multifactorial. The curriculum adheres to the general principles outlined over the last 2 decades,1Hebert R.S. Levine R.B. Smith C.G. Wright S.M. A systematic review of resident research curricula.Acad Med. 2003; 78: 61-68Crossref PubMed Scopus (85) Google Scholar, 5Alguire P.C. Anderson W.A. Albrecht R.R. Poland G.A. Resident research in internal medicine training programs.Ann Intern Med. 1996; 124: 321-328Crossref PubMed Scopus (81) Google Scholar, 13Schultz H.J. Research during internal medicine residency training: meeting the challenge of the residency review committee.Ann Intern Med. 1996; 124: 340-342Crossref PubMed Scopus (35) Google Scholar providing quantitative evidence in favor of these proposed support structures. In particular, key features of this curriculum include a formal resident project proposal review process, protected research electives in all years of training, and significant support for presentation of results at regional, national, and international conferences. The full curriculum allows residents with previous publication experience to work on projects immediately on entering residency. However, it also provides sufficient support to enable the sizable majority of residents lacking prior experience as authors to achieve at least 1 peer-reviewed publication during their training. In fact, residents with no pre-residency publications exposed to the Mayo curriculum had a higher rate of publication than residents with pre-residency publications who selected alternative training environments. Furthermore, the curriculum provides equal opportunity and support to all residents, such that pre-residency imbalances seen between men and women in authorship roles are effectively removed in the Mayo Clinic program. This analysis is particularly noteworthy given the growing body of literature documenting gender differences in academic and leadership positions that do not favor women.19Tesch B.J. Wood H.M. Helwig A.L. Nattinger A.B. Promotion of women physicians in academic medicine Glass ceiling or sticky floor?.JAMA. 1995; 273: 1022-1025Crossref PubMed Scopus (400) Google Scholar, 20Wright A.L. Schwindt L.A. Bassford T.L. et al.Gender differences in academic advancement: patterns, causes, and potential solutions in one US College of Medicine.Acad Med. 2003; 78: 500-508Crossref PubMed Scopus (212) Google Scholar, 21Reed D.A. Enders F. Lindor R. McClees M. Lindor K.D. Gender differences in academic productivity and leadership appointments of physicians throughout academic careers.Acad Med. 2011; 86: 43-47Crossref PubMed Scopus (220) Google Scholar With evidence to suggest that women enter residency with equivalent interest in academic careers compared with men, but less interest by the completion of residency,22Leonard J.C. Ellsbury K.E. Gender and interest in academic careers among first- and third-year residents.Acad Med. 1996; 71: 502-504Crossref PubMed Scopus (50) Google Scholar our data showing strikingly similar publication rates for men and women who complete the Mayo Clinic program versus the comparison group may help inform approaches to address this gender imbalance in academic medicine. This study has limitations. First, the pool of candidates interviewing at Mayo Clinic may differ from national demographics. For example, the study cohorts included more men and fewer international medical graduates than are seen nationally in internal medicine training programs.17Brotherton S.E. Etzel S.I. Graduate medical education, 2006-7.JAMA. 2007; 298: 1081-1096Crossref PubMed Scopus (62) Google Scholar Therefore, the results of this curriculum may be most applicable to university-based residency programs. Second, it is possible that some publications were missed because of name changes or database limitations. Because we intentionally restricted searches for Mayo residents to treat them in identical fashion to non-Mayo residents, this potential bias would be expected to affect both groups similarly. Third, we did not measure other markers of scholarship, such as poster presentations, book chapters, internal program documents, or grant support. Finally, further research is needed to determine if the increased productivity associated with the Mayo curriculum is sustained into residents' future careers. Research is a required element of residency training, but many programs struggle to satisfy this requirement. We demonstrate a successful comprehensive research curriculum associated with increased scholarly productivity among internal medicine residents. Thoughtful attention to research opportunities can stimulate scholarly pursuits that benefit residents, faculty, and patients.