Monday, May 21, 2018

The requirement that residents must be involved in research should be abolished

In a 2012 blog post called “Things that puzzle me about surgical education,” I wrote the following:

“There was the emphasis that still exists today on making sure every resident did research. At last, some are questioning the value of this for the average clinical surgeon. Contrary to the prevailing wisdom, there is no evidence that a resident who is dragged kicking and screaming through a clinical research project or who spent a year in someone’s lab really learns anything about research or how to read and understand a research paper.”

Nothing has changed.

According to the ACGME Program Requirements for Graduate Medical Education in General Surgery Section II.B.5.e: Clinical and/or basic science research must be ongoing in the residency program; based at the institution where residents spend the majority of their clinical time; and performed by faculty with frequent, direct resident involvement.

Last month the Journal of the American College of Radiology published a Point/Counterpoint on the value of resident research. Two academic radiologists took the “Point” position that required research in radiology residency programs should be eliminated.

To support their position, they cited the following:
  • Only 23% of practicing radiologists work in academia. 
  • Even a full year of research is not enough time to investigate a subject and have it presented or published. 
  • Many other topics such as health care economics, global health, and dealing with independent practice should be taught in lieu of research. 
  • Resident research is usually of low quality and the time spent is “of limited utility to most residents entering practice.” 
As a former chief of surgery and director of a small community hospital residency program, I agree with the authors’ statement, “Among the myriad struggles inherent to smaller programs is a relative lack of scientific pedigree, hospital research coordinators, and statistical support staff members enjoyed by programs sponsored by research-intensive universities.”

I would add that most faculties in small programs do not have the time, the desire, or the ability to do research.

My favorite quote from the paper is “Under the current paradigm of radiology GME, programs fritter away trainees’ valuable time on mandatory research projects, then send them out into the real world as sheep among wolves, unprepared for the harsh reality of clinical practice.”

The authors point out that because of the “exponential rise in mandatory ACGME requirements,” the curriculum for residency education is a zero-sum game. In other words, there’s only so much time for resident education, and the time should be spent more wisely.

A radiologist from Boston University took the Counterpoint that research by radiology residents is meaningful and important. To support his argument, he referenced a paper that stated “an analysis of factors influencing radiologists’ career decisions found that those who published in residency were 26.4 times more likely to choose an academic position as a first job.” This is a classic example of correlation not necessarily equaling causation. It is likely that residents who published during residency were more interested in becoming academic radiologists in the first place.

He also said that mandates worked because another paper found that “the institution of a resident research requirement at a university-based orthopedic department led to a 9-fold increase in peer-reviewed manuscripts with the resident co-authors in a three-year period.” Of course it did. Research was MANDATED. Who knows whether the research was impactful or had any effect on the residents’ careers?

Substitute the word “surgery" for “radiology." The situation is the same.

Instead of research, surgery residents would be far better off learning how to read a journal article, basic statistics, the nuances of CPT and ICD-10 codes, how to negotiate a contract, and how to manage their personal lives, finances, and debt.

No one says programs can’t make residents do research. Why not leave it up to each program to decide?

8 comments:

George Gasman said...

*Outstanding* post. Thank you.

The first 9 years of my career were spent in academia. I did no research as a trainee, and my CV is abysmally short with regard to publications and research.

However, I was a good teacher, a good administrator, and a good clinician. I was blessed that my chairman appreciated those qualities. My training as an anesthesiologist required no "basic science research" and it never affected my ability to care for my patients.

Korhomme said...

I entirely agree with your penultimate paragraph. Knowing the limits of research is much more useful than doing it for the majority of clinicians. Knowing how to read an article and to see which ones are valuable and which are dross; knowing the elements of statistics to make it possible to see when authors are bluffing are far more useful than doing research for the sake of publications or polishing the CV.

I did an intercalated BSc as a medical student in the UK; I rapidly learned that I was not suited to research, and I refused to do the post-graduate work for an MD. Despite this, I still got to be a consultant.

Dr Skeptic said...

Thanks for this. I agree that CONDUCTING research is not essential. While I also believe that conducting GOOD research can help trainees understand research and scientific methods, there are other ways of achieving this. In Australia, for orthopaedic training, we recently removed the requirement of conducting research, but only if they undergo accredited training in critical appraisal / epidemiology / statistics.

Anonymous said...

In addition to your excellent suggestions Skeptical, as a patient having at least EIGHT surgeries, surgery residents would be far better off learning how to get another 50+ cases of open surgeries and 100+ cases of lap surgeries by being the true chief surgeon (read ALONE). We don't care if you can pi to the 125th digit while performing a lap choly. We are getting older, fatter, with more complications like hypertension, asthma, diabetes and NAFLD. I can assure you not one of us going under your scalpel would prefer a Word corrected document to the ability to hang cool and get us through surgery alive/well at the end.

I can guarantee you the vultures that hire you would prefer you stay out of the malpractice arena, which more practice vs. paper pushing will do. Those who can, operate. Those who can't, are admins thinking up MOC test questions. Remember that.

Anonymous said...

Uttering the "shoot me" comment: could the 26.4 times more likely to choose an academic position as a first job be women? In other words, a desk job would be preferable and more amenable to a family life?

Skeptical Scalpel said...

Thanks for all the supportive comments. Anon from May 22, you are on your own with that one.

Anonymous said...

While I understand the perspective the writer is coming from, I believe it is a bit short-sighted and absolutist. Required breadth of education is required at all levels, from middle school to medical school - doesn't matter if you think you will not need it, because one can never predict their future. Some people enter surgery residency thinking for sure they want to become a CT surgeon - but because of the required rotations, they may realize their passion is in surgical oncology. Academic residency programs need to train residents to be capable in both academic and private practice, as many residents do not truly know which they would be happiest.

Academicians are our crucial link to the future and we must do all we can to encourage them, train them, and uncover unrealized interests and talents - they are the ones who advance our fields with their research and they train all of our future physicians who will carry our specialty forward. I think the main flaw I am reading here is the goal of a research requirement. The goal of the research requirement is not a binary outcome such as a high-impact publication in NEJM. The goal is to gain exposure, experience, and training in research. I have met many a resident who assumed they had no ability or interest in research, but thanks to the research requirement, they discovered a talent and passion that drove them into an unexpected career in academics. On the other hand, if, after completing a research requirement, that person has zero interest in research, then they may enter private practice fully knowing that they were not meant to be an academic.

Instead of saying that all residencies should require research, or that no programs should require research, I believe that academic residencies should have a research requirement, and community hospital residencies should not require research.

Skeptical Scalpel said...

Anon from 5/28/18, thanks for commenting. You had me worried with your first two paragraphs, but I was relieved to see the third one. I never said research should not be done. I said it shouldn't be required of all residents. If a university or any other program wants to require its residents to be involved in research, that is fine with me.

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