ORIGINAL REPORTS
Attitudes Toward Research During Residency: A Survey of Canadian Residents in Obstetrics and Gynecology Aisling A. Clancy, MD, MSc,* and Glenn Posner, MDCM, FRCSC, MEd*,† *
Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada; and Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
†
OBJECTIVES: Obstetrics and Gynecology (Ob/Gyn) residency programs in Canada mandate participation in scholarly research activity, yet there remains a lack of literature on trainees’ opinions regarding its value, feasibility, and perceived effect on future practice. An understanding of resident attitudes toward research during residency is essential in effectively engaging trainees and fostering a robust research community in the field. We sought to identify factors reported to influence involvement in resident research, including perceived barriers. DESIGN: Anonymous data were collected via an online
survey distributed to all residents enrolled in accredited Ob/ Gyn residency programs throughout Canada. The 10minute, previously piloted questionnaire covered questions related to demographic information, research experience, career goals, current research activities, opinions on research environment, and opinions regarding the effect of research on future practice. Descriptive statistics were used to describe demographics, research background, and current research activities. Categorical variables were compared using the chi-square analysis and continuous variables were compared using the Mann-Whitney rank sum tests. RESULTS: A total of 175 residents completed the survey; 61% agreed/strongly agreed that they participate in research solely because it is mandated by their program, 22% felt that their training environment did not promote research, 19% disagreed/ strongly disagreed that research is a positive experience, while 70% agreed/strongly agreed that they would prefer to complete another educational activity other than a research project. Time constraints owing to residency duties, time constraints owing to personal reasons, and lack of statistical knowledge were reported as barriers to research involvement by 97%, 90%, and 74% of trainees, respectively. Residents with graduate degrees were less
Correspondence: Inquiries to Aisling Anne Clancy, MD, MSc, Department of Obstetrics and Gynecology, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6; fax: (613) 737 8687; e-mail: [email protected]
836
likely to report lack of training on research design as a moderate/ extreme barrier (7% vs 32%, p ¼ 0.007). CONCLUSIONS: There exists considerable disparity in enthusiasm for scholarly research activity among Ob/Gyn residents. Curricular development should focus on addressing resident-reported barriers, including the provision of protected time for research and access to statistical support and education, particularly for residents without graduate degrees. ( J Surg Ed C 2015 Association of Program Directors in 72:836-843. J Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: graduate medical education, research, cur-
riculum, medical residency COMPETENCIES: Practice-Based Learning and Improvement,
Professionalism, Medical Knowledge, Systems-Based Practice
INTRODUCTION Although most specialists in Obstetrics and Gynecology (Ob/ Gyn) do not incorporate research into their practice, involvement in this scholarly activity is considered an essential component of Canadian residency specialty training. Indeed, the Royal College of Physicians and Surgeons of Canada mandates “active participation in the development, execution, data analysis, interpretation, and presentation of at least one scholarly research project”1 for certification in Ob/Gyn. The Association of Academic Professionals in Obstetrics and Gynecology (APOG) has outlined recommended expectations for resident research activity,2 pushing programs to develop mandatory research curricula. In defense of this requirement are multiple benefits ascribed to the experience, irrespective of future participation in research, including that it promotes an appreciation for evidence-based medicine, improves overall resident satisfaction with their training program,3 provides the skill set required for critical thinking and lifelong learning,4,5 fosters mentorship relationships, and influences career choice.4-6
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.02.007
Additional benefits for those who wish to pursue an academic practice include the opportunity to lay the groundwork for continued scholarly work4,5 and associated future academic success, as measured by enhanced publication rates and awarding of external funding.7 However, trainee interest in pursuing research is inconsistent, varying by specialty,8-10 career goals,10 personality traits,11 previous training,10,12 and previous research experience.8 Studies in other specialities show that many trainees feel that research should not be mandatory and report that they would instead prefer to undertake other academic activities.9 Similar attitudes may be prevalent in Ob/Gyn—a field in which up to 80% of residents do not pursue fellowship training.13 Compounding this variable interest among trainees are numerous reported obstacles to resident research involvement, including a lack of time,3,10,14 a lack of interest among faculty or an overall perceived paucity of mentors,3,10,14 and the resultant sense of few opportunities to become involved.10 Furthermore, program support may not adequately meet the needs of residents in order to succeed in research endeavors. For instance, a survey of Canadian and American Ob/Gyn program directors found that although 95% required residents to complete a research project to graduate, most programs did not provide formal training on clinical research design or biostatistics.15 The field of Ob/Gyn poses yet another set of distinct obstacles to resident involvement in research. The specialty has a high proportion of women, who have been shown to engage in less research,14 receive less National Institutes of Health (NIH) grant funding even when correcting for publication experience,16 and are less likely to advance to full professor status17 compared with their male counterparts. Moreover, unique ethical considerations for studies involving obstetrical patients18 as well as patients’ desire for privacy when investigating sexual health-related issues19 may render certain aspects of research projects (e.g., patient recruitment) 0%
10%
20%
more challenging than in other specialties. A more recent survey study on adherence to accreditation-driven guidelines among American Ob/Gyn residency programs reported that although 99% of program directors felt that research was a goal of their program, 17% of residents did not agree that their training environment promoted research.20 Despite being a mandatory component of Canadian residency training, there are limited data on Ob/Gyn resident attitudes toward research activity during residency. Insight into factors underlying their enthusiasm toward research, their assessments of their research environments, and the perceived barriers to their success in this domain are key to implementing effective research curricula in residency training and, in the case of some trainees, optimally nurturing the early stages of future research-oriented careers in the field.
METHODS An online-based survey was distributed to all Canadian Royal College–accredited Ob/Gyn residency programs (SurveyMonkey, Palo Alto, CA) in June 2014. Perceived research barriers and measures of attitudes toward research were identified based on interviews with residents and staff involved in research curricula, in addition to extensive literature review. Survey questions were developed according to the protocol by Artino et al.21 The survey was edited by a committee of 4 staff obstetrician-gynecologists involved in medical education and the research curriculum at the University of Ottawa. Questions were reviewed with the Ottawa Hospital Methods Centre for statistical analysis planning and design. Our pilot study was completed by 21 residents in April 2014, using Ob/ Gyn residents registered at the University of Ottawa (n ¼ 38) to assess feasibility, response times, and question validity. The final survey questions are shown in Appendix A. 30%
40%
50%
60%
70%
80%
90% 100%
Time constraints (residency dues) Time constraints (personal) Lack of stascal knowledge Lack of training on study design Lack of personal interest Lack of faculty support/mentorship Lack of funding Ethics approval Lack of relevant research queson Inability to recruit paents Equipment availability Extreme barrier
Moderate barrier
Somewhat of a barrier
Not a barrier
No experience
FIGURE. Barriers to research as reported by Canadian Ob/Gyn residents. Journal of Surgical Education Volume 72/Number 5 September/October 2015
837
The survey (Appendix A) consisted of a 10-minute questionnaire comprising 6 sections with 68 data points. The 6 areas assessed were as follows: (1) demographic information, (2) research experience, (3) career goals, (4) current research activities, (5) opinions regarding their research environment, and (6) opinions regarding the effect of research on future practice. Questions were formatted as multiple choice, yes or no, short answer, and 5-point Likert scales requiring mandatory responses. There were free-text response options for additional comments. The study was approved by the Ottawa Hospital Research Institute Research Ethics Board. Participants were contacted through program administrators at each site. We circulated 2 additional reminder e-mails 2 and 4 weeks after the initial survey distribution. Participants were offered the opportunity to be entered into a prize draw for 5 gift cards of $100 value. We aimed to recruit 164 participants, which would provide a 5% margin of error for a survey response of 20% using a 95% CI. Eligible subjects included individuals who declared themselves to be residents in Ob/Gyn and who were contacted via program administrators at 1 of the 16 accredited residency programs in Canada. All the residency programs in Canada are affiliated with tertiary-care academic institutions and enjoy access to university resources. Program administrators provided the number of active registered residents in their respective programs for response rate calculations. Descriptive statistics were used to describe demographics, research background, and current research activities. Likert scale agreement responses of 4 and 5 were grouped together as were disagreement responses of 1 and 2. Neutral responses were included in the analysis. Categorical variables were compared using the chi-square analysis. Continuous variables (such as age and estimates of time) were compared using Mann-Whitney rank sum tests. A standard α ¼ 0.05 was used to define statistical significance. Statistical analyses were performed using SigmaStat 3.5 (Systat Software, Germany).
RESULTS Of 484 subjects contacted, 175 (36%) completed the survey in full. Respondents included residents from all 16 programs across Canada and from all stages of residency training as determined by postgraduate year (PGY). Demographic information and research experience before starting residency are summarized in Table 1. Residents reported dedicating a median of 5 hours per month toward research projects (interquartile range [IQR]: 1.5-10.0) with a mode of 1. Overall, 98% of respondents reported that their programs participated in a resident research day/event; however, only 58% had presented research in this forum, with fewer having presented in larger conference settings (Table 2). Nearly 1 in 5 residents reported having published in peer-reviewed journals during residency. 838
TABLE 1. Demographics and Baseline Research Experience Before Starting Ob/Gyn Residency All Respondents (n ¼ 175) Gender Female 156 Male 19 Median age 29 PGY level PGY1 42 PGY2 32 PGY3 44 PGY4 28 PGY5 29 Family status 29 Child/children* No children 146 Research experience before starting residency 27 Master’s degree† 5 PhD† Worked in research before residency 71 Research in medical school 116 Research during undergraduate 109 education Undergraduate thesis 63
(89%) (11%) (IQR: 27-31) (24%) (15%) (25%) (16%) (17%) (17%) (83%) (15%) (3%) (41%) (66%) (62%) (36%)
*28 Respondents reported that they had their child/children during residency. † 4 Respondents reported completing combined MD/graduate degree programs, and all these individuals reported holding PhD degrees.
Attitudes Regarding Research, Research Environment, and Influence on Career Goals Overall, 94% of respondents reported that 1 of their motivators for participating in research was their program’s requirement, 72% reported that they were engaged in research for career advancement, 27% disagreed with the statement that they participated for personal interest (Appendix B Supplemental Table S1). Overall, 46% of residents felt that engaging in research is a positive experience but 22% disagreed; 51% agreed that their training environment promotes scholarly research activity; 38% of residents intended to pursue research as an attending physician; 31% agreed that involvement in resident research increased their desire to pursue this option, whereas 41% disagreed; 54% of residents felt that involvement in research increased the likelihood that they would assist in future research projects, whereas a lesser proportion (34%) felt that it would increase the likelihood of initiating projects (Table 3). Perceived Barriers to Scholarly Research Activities The most commonly identified barrier to research was time constraints owing to residency duties, with 97% reporting this as a barrier (Fig.). Other prominent barriers included time constraints owing to personal commitments and lack
Journal of Surgical Education Volume 72/Number 5 September/October 2015
TABLE 2. Research Activities During Ob/Gyn Residency All Respondents (n ¼ 175) Research experience Currently enrolled in clinician investigator program* Completed a grant proposal Completed a research ethics board application Completed a research methods course Published in a peer-reviewed journal Forums in which respondents have presented research International conference National conference Regional conference Resident research day Time spent on scholarly activity (hours per month) Resident research† Reading research literature‡ † ‡
9 41 115 107 34
(5%) (23%) (66%) (61%) (19%)
45 73 45 102
(26%) (42%) (26%) (58%)
5.0 (IQR: 1.5-10.0) 5.0 (IQR: 2.0-7.0)
*Clinical Investigator Program (CIP) is a combined residency and graduate degree program. Mode of 10 hours per month. Mode of 5 hours per month.
of statistical knowledge, which were reported by 90% and 74%, respectively. Overall, 16% reported that their program did not have dedicated research time. Representative examples of free-text comments regarding barriers included “our protected time is not in reality protected” and listed “approval from other governing bodies (not research ethics board).” Senior vs Junior Residents In comparing senior (PGY 4-5, n ¼ 57) and junior (PGY 1-3, n ¼ 118) residents, senior residents were older (median age ¼ 28 [IQR: 26.5-29] vs 31 y [IQR: 30-32], p o 0.001) and more likely to have children (32% vs 9%, p o 0.001). They more commonly reported a lack of statistical knowledge and inability to recruit patients as moderate/extreme barriers to research pursuits (47% vs 34%; p ¼ 0.04, and
23% vs 8%; p o 0.01, respectively). Senior residents were more likely to have completed a research ethics board application (81% vs 58%, p ¼ 0.004). They more often disagreed that they participated in research for career advancement purposes (22% vs 7%, p ¼ 0.003) and that their research experience had made them “more likely to assist in future research projects” (30% vs 16%, p ¼ 0.03). There was no statistical difference in agreement with the statement that their research made them “more likely to initiate future research projects” when compared with junior trainees (35% vs 34%, p ¼ 0.44). Gender and Family Status There was no statistical difference between male (n ¼ 19) and female residents (n ¼ 156) regarding age, children,
TABLE 3. Resident Attitudes Regarding Research Experience, Research Environment, and Future Involvement
Attitudes regarding research experience/research environment “Resident research is a positive experience” “My training environment promotes research activity” “Rather than complete a research project, I would prefer to complete another educational activity” “I only do research because it is a mandatory part of my residency program” Attitudes regarding future involvement in research “I plan to do research when I am a staff physician” “Involvement in resident research has increased my desire to pursue research as a staff level physician”* “Involvement in resident research made me more likely to assist in future research projects”† “Involvement in resident research made me more likely to initiate future research projects”‡
Strongly Agree/ Agree
Neutral
Disagree/ Strongly Disagree
80 (46%) 90 (51%) 123 (70%)
62 (35%) 46 (26%) 32 (18%)
33 (19%) 39 (22%) 20 (11%)
106 (61%)
19 (11%)
50 (29%)
66 (38%) 54 (31%)
48 (27%) 39 (22%)
61 (35%) 71 (41%)
95 (54%)
32 (18%)
36 (21%)
60 (34%)
42 (24%)
60 (34%)
*11 (6%) Respondents answered “not applicable.” 12 (7%) Respondents answered “not applicable.” ‡ 23(13%) Respondents answered “not applicable.” †
Journal of Surgical Education Volume 72/Number 5 September/October 2015
839
prior research experience, career goals, reasons for participation in research, current research activities, perception of barriers to research, or questions related to attitudes regarding the effect of research on future practice. Residents with children (n ¼ 29) were older than those without (median age ¼ 31 y [IQR: 29-32] vs 28 [IQR: 2730], p o 0.001). Those with children more commonly reported publishing before residency (55% vs 34%, p ¼ 0.03). They were less likely to have applied for a grant (19% vs 41%, p ¼ 0.024) or have a research supervisor who published at least once per year (49% vs 79%, p ¼ 0.02). They reported a preference to develop their own research question rather than work on the one developed by their supervisor (10% vs 32%, p ¼ 0.003). Graduate Degree vs no Graduate Degree Residents with graduate degrees (Master’s degree or PhD, n ¼ 29) more often performed research in medical school (82% vs 62%, p ¼ 0.04), in undergraduate studies (83% vs 58%, p ¼ 0.01), and worked in research before residency (76% vs 34%, p o 0.001). Furthermore, they were more likely to report having applied for a grant (48% vs 18%, p o 0.001) and to report publishing in a peer-reviewed journal both before and during residency (83% vs 45%; p o 0.001, and 31% vs 17%; p ¼ 0.04, respectively) (Table 4). Residents without graduate degrees more often rated lack of training on research design as a moderate or extreme barrier (32% vs 7%, p ¼ 0.007). They more often reported being encouraged by a mentor (57% vs 38%, p ¼ 0.02). Residents with graduate degrees were more likely to report intention to undertake research as a staff physician (55% vs 34%, p ¼ 0.03) and a larger proportion agreed that they would assist with research projects in the future (72% vs 51%, p o 0.01). There was no difference in plans to initiate future research projects between these groups. Those with graduate degrees less often agreed with the statements “Rather than complete a research project, I would prefer to complete another educational activity” (52% vs 74%, p ¼ 0.03) and “I only do research because it is a mandatory part of my residency training” (38% vs 65%, p ¼ 0.01). Dedicated Program Research Time Attitudes of those who reported having dedicated research time, when compared with those without, were similar regarding most barriers. Those who reported having dedicated research time were more likely to report faculty support as a barrier to research (35 vs 17%, p o 0.01). Residents with dedicated research time were more likely to agree/strongly agree that their training environment promotes research (42% vs 7%, p o 0.01) and to agree/ strongly agree that they have supports for research at their institution (46% vs 7%, p ¼ 0.02). They more often agreed/strongly agreed that they would assist with research 840
projects in the future (42% vs 12%, p o 0.01). A greater proportion of those reporting dedicated research time agreed/strongly agreed that they only do research because it is a mandatory part of their residency (39% vs 15%, p o 0.01).
DISCUSSION Despite the inclusion of scholarly research activity as a requirement for successful completion of residency training in Ob/Gyn, resident attitudes toward this component of their training remains poorly characterized. The nature of this specialty, including its unique patient population, may render the resident research experience distinct from that of residents in other areas of medicine, including other surgical specialties. We therefore aimed to describe, as reported by Ob/Gyn residents, the extent of their involvement in research activities, motivators and barriers to their involvement, and the effect participating in research has had on their future career plans. We also collected data regarding pre-existing research experience (specifically through formal graduate degrees), seniority in residency training, gender, and family status to identify potentially influencing factors. The response rate of 36% is reasonable and higher than many other similarly designed studies (8%-47%)20,22-27 perhaps because we used 2 reminders and provided participation incentives. Perhaps the most striking findings of this study are that only half of Ob/Gyn residents felt that their training environment promoted research activities and that nearly one-fifth disagreed with the statement that “resident research is a positive experience.” Overall, 61% reported that they only participate in research because it is a mandatory component of their residency training and 70% reported that they would prefer to complete another educational activity—a rate comparable to that among anesthesiology residents.9 Clearly, our findings argue that there is considerable room for improvement in developing research curricula to better engage learners. More positive attitudes were observed among trainees with graduate degrees. This subset of trainees has arguably demonstrated a greater interest in research during medical school12; therefore, it is reasonable to assume that this interest continues into residency. In addition to suboptimal interest and enthusiasm among trainees, 2 leading reported barriers to resident research found in our study relate to time constraints. In fact, half of residents reported residency duties as representing an extreme barrier. Protected research time, either as a research rotation or an additional year dedicated to research, has been shown to improve research productivity in anesthesiology,9 internal medicine,28 emergency medicine,29 and general surgery.30 In our survey, provision of dedicated research time was associated with positive influences on
Journal of Surgical Education Volume 72/Number 5 September/October 2015
TABLE 4. Research Activities, Previous Experience and Attitudes Toward Research by Graduate Degree Status Master’s or PhD (n ¼ 29) Demographics Male gender Child/children Age (median) Senior resident (PGY 4-5) Previous research experience Worked in research before residency Research in medical school Research during undergraduate education Undergraduate thesis Published in a peer-reviewed journal before residency None Scholarly research activities Completed a grant application Completed a research ethics board application Completed a research methods course Published in a peer-reviewed journal during residency Attitudes toward research activities Agree or strongly agree with the statements: “Rather than complete a research project, I would prefer to spend time completing another educational activity” “I only do research because it is a mandatory part of my residency training” Agree or strongly agree that involvement in resident research has made them more likely to: “Initiate future research activities” “Assist in future research activities”
attitudes toward research including feeling that they were supported at their institution and anticipation that they would assist with research in the future. Currently, however, rotations dedicated to research are generally considered “selectives” by Canadian accrediting bodies with no mandate for protected time.1 Structured research mentorship31 or appointment of a resident research director or both32 are also potential strategies for provision of research support, both of which have been shown to improve resident research productivity. The optimal approach likely varies by institute and specialty. For instance, Fischer and Cation33 reported that having an appointed resident research director had a greater effect on research productivity than protected resident research time for their internal medicine program. However, in our survey, 97% of residents identified time constraints owing to residency duties as a barrier compared with only 59% who identified lack of faculty support/mentorship. Lack of statistical knowledge was also considered a major barrier to research activity among residents, though less so for those with graduate degrees. Interestingly, senior residents (PGY 4-5) more commonly reported lack of statistical knowledge as a barrier, perhaps because juniors were not yet in the analysis phase of their research. In a survey of American and Canadian Ob/Gyn program directors regarding research education curricula, 58% reported having a designated biostatistician and 47% had didactic sessions on
No Graduate Degree (n ¼ 146)
pValue
3 3 28 9
(10%) (10%) (IQR: 27-31) (31%)
15 26 29 48
(10%) (18%) (IQR: 27-31) (32%)
0.99 0.32 0.89 0.84
22 24 24 15 24 2
(76%) (83%) (83%) (52%) (83%) (7%)
49 92 85 48 66 22
(34%) (63%) (58%) (33%) (45%) (15%)
o0.001 0.04 0.01 0.05 o0.001 0.24
14 22 17 9
(48%) (75%) (59%) (31%)
27 93 90 25
(19%) (64%) (61%) (17%)
o0.001 0.20 0.76 0.04
15 (52%)
108 (74%)
0.04
11 (32%)
95 (65%)
0.01
11(38%) 21 (72%)
48(35%) 74 (50%)
0.19 0.008
biostatistics and epidemiology.15 Attendance at a research methodology course has been shown to improve research productivity among surgical residents.34 Instituting and preserving such support systems as well as ensuring resident awareness of local resources for research assistance may aid them in their research pursuits. Almost half of our survey respondents listed lack of funding as a barrier to research, yet only 23% had completed a grant proposal. This raises the questions of whether grants are directed to areas of resident research and whether residents feel qualified and supported in applying for funding. Levine et al.35 found that having funding designated for resident scholarship was associated with decreased odds of a program being “cited for lack of scholarship activity.” Similarly, a study of Ob/Gyn resident research projects attributed increased frequency of research publications and presentations at national meetings in part to the initiation of an endowment fund.36 The main strengths of our study include that it represents a national sampling of residents and that it used a comprehensive survey regarding motivators, research activities (both pre-existing and during residency), and perceived barriers to research endeavors, thereby providing insight into potential targets for program development. Limitations of our study include the self-reported nature of the data and potential for responder bias, and reliance on program administrators to forward the survey. The survey req-
Journal of Surgical Education Volume 72/Number 5 September/October 2015
841
uested self-reported information regarding publications, presentations, and time spent on research pursuits. Independent verification of this data was not possible. The number of residents who received and read the invitation to complete the survey is not known as the study personal did not receive “failure to deliver” e-mail responses directly. Response rates were based on number of active residents as declared by program administrators. Small monetary participation incentives have been shown to reduce nonresponse error among survey participants,37 especially in studies with topic bias.38 Incentives were used in our study, particularly to encourage participation among individuals who were not highly involved or interested in research pursuits; however, the success of this approach is not known.
3. Takahashi O, Ohde S, Jacobs JL, Tokuda Y, Omata F,
CONCLUSIONS
7. Hsieh H, Paquette F, Fraser SA, et al. Formal research
Leading barriers to Ob/Gyn resident research pursuits, as reported by the residents themselves, include lack of time owing to clinical duties, lack of time owing to personal duties, and lack of understanding of statistical principles. Our data suggest that strategies to improve resident research involvement should include protected research time and statistical support with consideration given to formal research mentorship and appointment of a resident research director. Many residents do not feel that their training environment promotes research and one-fifth of residents did not feel that residency research was a positive experience. Further work is needed to evaluate whether a change in research curricula can improve the residency research experience.
Fukui T. Residents’ experience of scholarly activities is associated with higher satisfaction with residency training. J Gen Intern Med. 2009;24(6):716-720. 4. Toledo-Pereyra LH. Becoming a surgical scholar.
J Invest Surg. 2011;24(4):139-140. 5. Turnberg LA. The place of research in the training of
NHS consultant physicians. J R Coll Physicians Lond. 1993;27(4):403-404. 6. Dodge JE, Chiu HH, Fung S, Rosen BP. Multicentre
study on factors affecting the gynaecologic oncology career choice of canadian residents in obstetrics and gynaecology. J Obstet Gynaecol Can. 2010;32(8): 780-793. training during surgical residency: scaffolding for academic success. Am J Surg. 2014;207(1):141-145. 8. 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(4):366-369. 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(3):859-864. 10. Ullrich N, Botelho CA, Hibberd P, Bernstein HH.
Research during pediatric residency: predictors and resident-determined influences. Acad Med. 2003;78 (12):1253-1258.
ACKNOWLEDGMENTS
11. Salgueira A, Costa P, Goncalves M, Magalhaes E,
We are grateful to our panel of experts (Drs. Jay Baltz, Andrée Gruslin, and Tien Le) for their assistance with survey questionnaire development, to the Academy for Innovation in Medical Education for research funding support, and to the Ottawa Hospital Research Institute Methods Centre for assistance with statistical analysis.
12. Siemens DR, Punnen S, Wong J, Kanji N. A survey
Costa MJ. Individual characteristics and student’s engagement in scientific research: a cross-sectional study. BMC Med Educ. 2012;12:95. on the attitudes towards research in medical school. BMC Med Educ. 2010;10:4. 13. Rayburn WF, Gant NF, Gilstrap LC, Elwell EC,
Williams SB. Pursuit of accredited subspecialties by graduating residents in obstetrics and gynecology, 2000-2012. Obstet Gynecol. 2012;120(3):619-625.
REFERENCES 1. Canada RCoPaSo. Specialty Training Requirements in
Obstetrics and Gynecology. Available at: 〈http://www. royalcollege.ca/rc/faces/oracle/webcenter/portalapp/ pages〉; 2013. Accessed 08.13.
2. Smith GN, McNamara H, Bessette P, et al. Resident
research training objectives and requirements of the association of academic professionals in obstetrics and gynaecology. J Obstet Gynaecol Can. 2011;33(10): 1044-1046. 842
14. Gill S, Levin A, Djurdjev O, Yoshida EM. Obstacles
to residents’ conducting research and predictors of publication. Acad Med. 2001;76(5):477. 15. Kenton K, Brubaker L. Research education in obstet-
rics and gynecology: how are we doing? Am J Obstet Gynecol. 2007;197(5):532.e1-532.e4. 16. Svider PF, D’Aguillo CM, White PE, et al. Gender
differences in successful National Institutes of Health
Journal of Surgical Education Volume 72/Number 5 September/October 2015
funding in ophthalmology. J Surg Educ. 2014;71(5): 680-688. 17. Sexton KW, Hocking KM, Wise E, et al. Women in
academic surgery: the pipeline is busted. J Surg Educ. 2012;69(1):84-90. 18. Reid R, Susic D, Pathirana S, Tracy S, Welsh AW.
The ethics of obtaining consent in labour for research. Aust N Z J Obstet Gynaecol. 2011;51(6):485-492. 19. Ching SL, Gates EA, Robertson PA. Factors influenc-
ing obstetric and gynecologic patients’ decisions toward medical student involvement in the outpatient setting. Am J Obstet Gynecol. 2000;182(6):1429-1432. 20. Oakley SH, Crisp CC, Estanol MV, Fellner AN,
Kleeman SD, Pauls RN. Attitudes and compliance with research requirements in OB/GYN residencies: a national survey. Gynecol Obstet Invest. 2013;75(4): 275-280. 21. Artino AR Jr, Gehlbach H, Durning SJ. AM last page:
avoiding five common pitfalls of survey design. Acad Med. 2011;86(10):1327.
22. Antosh DD, Gutman RE, Iglesia CB, Sokol AI, Park
AJ. Resident opinions on vaginal hysterectomy training. Female Pelvic Med Reconstr Surg. 2011;17(6): 314-317. 23. Jacob KA, Bell J, Francis S. Resident training in female
sexual dysfunction: a comparison of urology and obstetrics and gynecology programs. Female Pelvic Med Reconstr Surg. 2011;17(5):238-241. 24. Chapman SJ, Hakeem AR, Marangoni G, Raj Prasad
K. How can we enhance undergraduate medical training in the operating room? A survey of student attitudes and opinions. J Surg Educ. 2013;70(3): 326-333. 25. Ivanovic J, Maziak DE, Gilbert S, et al. Assessing the
preferences of surgical residents toward laparoscopic simulation training: a resident survey. J Surg Educ. 2014;71(5):727-733. 28. Hepburn MJ, Battafarano DF, Enzenauer RJ, et al.
Increasing resident research in a military internal medicine program. Mil Med. 2003;168(4):341-345. 29. 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(4): 356-359. 30. Thomas JB, Cofer JB, Lewis PL, Burns RP. Clinical
research during surgery residency: the Chattanooga approach. Curr Surg. 2000;57(2):135-139. 31. Ogunyemi D, Solnik MJ, Alexander C, Fong A, Azziz
R. Promoting residents’ professional development and academic productivity using a structured faculty mentoring program. Teach Learn Med. 2010;22(2):93-96. 32. Durning SJ, Cation LJ, Ender PT, Gutierrez-Nunez
JJ. A resident research director can improve internal medicine resident research productivity. Teach Learn Med. 2004;16(3):279-283. 33. Fischer JL, Cation LJ. Impact of a residency research
program on research activity, faculty involvement, and institutional cost. Teach Learn Med. 2005;17(2): 159-165. 34. Farrokhyar F, Amin N, Dath D, et al. Impact of the
surgical research methodology program on surgical residents’ research profiles. J Surg Educ. 2014;71(4): 513-520. 35. Levine RB, Hebert RS, Wright SM. Factors associated
with citation of internal medicine residency programs for lack of scholarly activity. Teach Learn Med. 2005;17(4):328-331.
status of thoracic surgical research and quality improvement programs: a survey of the members of the canadian association of thoracic surgeons. J Surg Educ. 2011;68(4):258-265.
36. Morrison JC, Meeks GR, Martin JN Jr, Cowan BD,
26. Kroft J, Moody JRK, Lee P. Canadian Hysterectomy
37. Adua L, Sharp JS. Examining survey participation and
Educational Experience: survey of recent graduates in obstetrics and gynecology. J Minim Invasive Gynecol. 2011;18(4):438-444.
response quality: the significance of topic salience and incentives. Surv Methodol. 2010;36(1):95-109.
27. Shetty S, Zevin B, Grantcharov TP, Roberts KE,
Duffy AJ. Perceptions, training experiences, and
Whitworth NS, Wiser WL. Resident research projects: frequency of presentation and publication in a national forum. Am J Obstet Gynecol. 1994;170(3):777-781.
38. Groves RM, Presser S, Dipko S. The role of
topic interest in survey participation decisions. Public Opin Q. 2004;68(1):2-31.
SUPPLEMENTARY MATERIALS Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2015.02.007. Journal of Surgical Education Volume 72/Number 5 September/October 2015
843
Attitudes Toward Research During Residency: A Survey of Canadian Residents in Obstetrics and Gynecology Aisling A. Clancy, MD, MSc,* and Glenn Posner, MDCM, FRCSC, MEd*,† *
Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada; and Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
†
OBJECTIVES: Obstetrics and Gynecology (Ob/Gyn) residency programs in Canada mandate participation in scholarly research activity, yet there remains a lack of literature on trainees’ opinions regarding its value, feasibility, and perceived effect on future practice. An understanding of resident attitudes toward research during residency is essential in effectively engaging trainees and fostering a robust research community in the field. We sought to identify factors reported to influence involvement in resident research, including perceived barriers. DESIGN: Anonymous data were collected via an online
survey distributed to all residents enrolled in accredited Ob/ Gyn residency programs throughout Canada. The 10minute, previously piloted questionnaire covered questions related to demographic information, research experience, career goals, current research activities, opinions on research environment, and opinions regarding the effect of research on future practice. Descriptive statistics were used to describe demographics, research background, and current research activities. Categorical variables were compared using the chi-square analysis and continuous variables were compared using the Mann-Whitney rank sum tests. RESULTS: A total of 175 residents completed the survey; 61% agreed/strongly agreed that they participate in research solely because it is mandated by their program, 22% felt that their training environment did not promote research, 19% disagreed/ strongly disagreed that research is a positive experience, while 70% agreed/strongly agreed that they would prefer to complete another educational activity other than a research project. Time constraints owing to residency duties, time constraints owing to personal reasons, and lack of statistical knowledge were reported as barriers to research involvement by 97%, 90%, and 74% of trainees, respectively. Residents with graduate degrees were less
Correspondence: Inquiries to Aisling Anne Clancy, MD, MSc, Department of Obstetrics and Gynecology, University of Ottawa, 501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6; fax: (613) 737 8687; e-mail: [email protected]
836
likely to report lack of training on research design as a moderate/ extreme barrier (7% vs 32%, p ¼ 0.007). CONCLUSIONS: There exists considerable disparity in enthusiasm for scholarly research activity among Ob/Gyn residents. Curricular development should focus on addressing resident-reported barriers, including the provision of protected time for research and access to statistical support and education, particularly for residents without graduate degrees. ( J Surg Ed C 2015 Association of Program Directors in 72:836-843. J Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: graduate medical education, research, cur-
riculum, medical residency COMPETENCIES: Practice-Based Learning and Improvement,
Professionalism, Medical Knowledge, Systems-Based Practice
INTRODUCTION Although most specialists in Obstetrics and Gynecology (Ob/ Gyn) do not incorporate research into their practice, involvement in this scholarly activity is considered an essential component of Canadian residency specialty training. Indeed, the Royal College of Physicians and Surgeons of Canada mandates “active participation in the development, execution, data analysis, interpretation, and presentation of at least one scholarly research project”1 for certification in Ob/Gyn. The Association of Academic Professionals in Obstetrics and Gynecology (APOG) has outlined recommended expectations for resident research activity,2 pushing programs to develop mandatory research curricula. In defense of this requirement are multiple benefits ascribed to the experience, irrespective of future participation in research, including that it promotes an appreciation for evidence-based medicine, improves overall resident satisfaction with their training program,3 provides the skill set required for critical thinking and lifelong learning,4,5 fosters mentorship relationships, and influences career choice.4-6
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.02.007
Additional benefits for those who wish to pursue an academic practice include the opportunity to lay the groundwork for continued scholarly work4,5 and associated future academic success, as measured by enhanced publication rates and awarding of external funding.7 However, trainee interest in pursuing research is inconsistent, varying by specialty,8-10 career goals,10 personality traits,11 previous training,10,12 and previous research experience.8 Studies in other specialities show that many trainees feel that research should not be mandatory and report that they would instead prefer to undertake other academic activities.9 Similar attitudes may be prevalent in Ob/Gyn—a field in which up to 80% of residents do not pursue fellowship training.13 Compounding this variable interest among trainees are numerous reported obstacles to resident research involvement, including a lack of time,3,10,14 a lack of interest among faculty or an overall perceived paucity of mentors,3,10,14 and the resultant sense of few opportunities to become involved.10 Furthermore, program support may not adequately meet the needs of residents in order to succeed in research endeavors. For instance, a survey of Canadian and American Ob/Gyn program directors found that although 95% required residents to complete a research project to graduate, most programs did not provide formal training on clinical research design or biostatistics.15 The field of Ob/Gyn poses yet another set of distinct obstacles to resident involvement in research. The specialty has a high proportion of women, who have been shown to engage in less research,14 receive less National Institutes of Health (NIH) grant funding even when correcting for publication experience,16 and are less likely to advance to full professor status17 compared with their male counterparts. Moreover, unique ethical considerations for studies involving obstetrical patients18 as well as patients’ desire for privacy when investigating sexual health-related issues19 may render certain aspects of research projects (e.g., patient recruitment) 0%
10%
20%
more challenging than in other specialties. A more recent survey study on adherence to accreditation-driven guidelines among American Ob/Gyn residency programs reported that although 99% of program directors felt that research was a goal of their program, 17% of residents did not agree that their training environment promoted research.20 Despite being a mandatory component of Canadian residency training, there are limited data on Ob/Gyn resident attitudes toward research activity during residency. Insight into factors underlying their enthusiasm toward research, their assessments of their research environments, and the perceived barriers to their success in this domain are key to implementing effective research curricula in residency training and, in the case of some trainees, optimally nurturing the early stages of future research-oriented careers in the field.
METHODS An online-based survey was distributed to all Canadian Royal College–accredited Ob/Gyn residency programs (SurveyMonkey, Palo Alto, CA) in June 2014. Perceived research barriers and measures of attitudes toward research were identified based on interviews with residents and staff involved in research curricula, in addition to extensive literature review. Survey questions were developed according to the protocol by Artino et al.21 The survey was edited by a committee of 4 staff obstetrician-gynecologists involved in medical education and the research curriculum at the University of Ottawa. Questions were reviewed with the Ottawa Hospital Methods Centre for statistical analysis planning and design. Our pilot study was completed by 21 residents in April 2014, using Ob/ Gyn residents registered at the University of Ottawa (n ¼ 38) to assess feasibility, response times, and question validity. The final survey questions are shown in Appendix A. 30%
40%
50%
60%
70%
80%
90% 100%
Time constraints (residency dues) Time constraints (personal) Lack of stascal knowledge Lack of training on study design Lack of personal interest Lack of faculty support/mentorship Lack of funding Ethics approval Lack of relevant research queson Inability to recruit paents Equipment availability Extreme barrier
Moderate barrier
Somewhat of a barrier
Not a barrier
No experience
FIGURE. Barriers to research as reported by Canadian Ob/Gyn residents. Journal of Surgical Education Volume 72/Number 5 September/October 2015
837
The survey (Appendix A) consisted of a 10-minute questionnaire comprising 6 sections with 68 data points. The 6 areas assessed were as follows: (1) demographic information, (2) research experience, (3) career goals, (4) current research activities, (5) opinions regarding their research environment, and (6) opinions regarding the effect of research on future practice. Questions were formatted as multiple choice, yes or no, short answer, and 5-point Likert scales requiring mandatory responses. There were free-text response options for additional comments. The study was approved by the Ottawa Hospital Research Institute Research Ethics Board. Participants were contacted through program administrators at each site. We circulated 2 additional reminder e-mails 2 and 4 weeks after the initial survey distribution. Participants were offered the opportunity to be entered into a prize draw for 5 gift cards of $100 value. We aimed to recruit 164 participants, which would provide a 5% margin of error for a survey response of 20% using a 95% CI. Eligible subjects included individuals who declared themselves to be residents in Ob/Gyn and who were contacted via program administrators at 1 of the 16 accredited residency programs in Canada. All the residency programs in Canada are affiliated with tertiary-care academic institutions and enjoy access to university resources. Program administrators provided the number of active registered residents in their respective programs for response rate calculations. Descriptive statistics were used to describe demographics, research background, and current research activities. Likert scale agreement responses of 4 and 5 were grouped together as were disagreement responses of 1 and 2. Neutral responses were included in the analysis. Categorical variables were compared using the chi-square analysis. Continuous variables (such as age and estimates of time) were compared using Mann-Whitney rank sum tests. A standard α ¼ 0.05 was used to define statistical significance. Statistical analyses were performed using SigmaStat 3.5 (Systat Software, Germany).
RESULTS Of 484 subjects contacted, 175 (36%) completed the survey in full. Respondents included residents from all 16 programs across Canada and from all stages of residency training as determined by postgraduate year (PGY). Demographic information and research experience before starting residency are summarized in Table 1. Residents reported dedicating a median of 5 hours per month toward research projects (interquartile range [IQR]: 1.5-10.0) with a mode of 1. Overall, 98% of respondents reported that their programs participated in a resident research day/event; however, only 58% had presented research in this forum, with fewer having presented in larger conference settings (Table 2). Nearly 1 in 5 residents reported having published in peer-reviewed journals during residency. 838
TABLE 1. Demographics and Baseline Research Experience Before Starting Ob/Gyn Residency All Respondents (n ¼ 175) Gender Female 156 Male 19 Median age 29 PGY level PGY1 42 PGY2 32 PGY3 44 PGY4 28 PGY5 29 Family status 29 Child/children* No children 146 Research experience before starting residency 27 Master’s degree† 5 PhD† Worked in research before residency 71 Research in medical school 116 Research during undergraduate 109 education Undergraduate thesis 63
(89%) (11%) (IQR: 27-31) (24%) (15%) (25%) (16%) (17%) (17%) (83%) (15%) (3%) (41%) (66%) (62%) (36%)
*28 Respondents reported that they had their child/children during residency. † 4 Respondents reported completing combined MD/graduate degree programs, and all these individuals reported holding PhD degrees.
Attitudes Regarding Research, Research Environment, and Influence on Career Goals Overall, 94% of respondents reported that 1 of their motivators for participating in research was their program’s requirement, 72% reported that they were engaged in research for career advancement, 27% disagreed with the statement that they participated for personal interest (Appendix B Supplemental Table S1). Overall, 46% of residents felt that engaging in research is a positive experience but 22% disagreed; 51% agreed that their training environment promotes scholarly research activity; 38% of residents intended to pursue research as an attending physician; 31% agreed that involvement in resident research increased their desire to pursue this option, whereas 41% disagreed; 54% of residents felt that involvement in research increased the likelihood that they would assist in future research projects, whereas a lesser proportion (34%) felt that it would increase the likelihood of initiating projects (Table 3). Perceived Barriers to Scholarly Research Activities The most commonly identified barrier to research was time constraints owing to residency duties, with 97% reporting this as a barrier (Fig.). Other prominent barriers included time constraints owing to personal commitments and lack
Journal of Surgical Education Volume 72/Number 5 September/October 2015
TABLE 2. Research Activities During Ob/Gyn Residency All Respondents (n ¼ 175) Research experience Currently enrolled in clinician investigator program* Completed a grant proposal Completed a research ethics board application Completed a research methods course Published in a peer-reviewed journal Forums in which respondents have presented research International conference National conference Regional conference Resident research day Time spent on scholarly activity (hours per month) Resident research† Reading research literature‡ † ‡
9 41 115 107 34
(5%) (23%) (66%) (61%) (19%)
45 73 45 102
(26%) (42%) (26%) (58%)
5.0 (IQR: 1.5-10.0) 5.0 (IQR: 2.0-7.0)
*Clinical Investigator Program (CIP) is a combined residency and graduate degree program. Mode of 10 hours per month. Mode of 5 hours per month.
of statistical knowledge, which were reported by 90% and 74%, respectively. Overall, 16% reported that their program did not have dedicated research time. Representative examples of free-text comments regarding barriers included “our protected time is not in reality protected” and listed “approval from other governing bodies (not research ethics board).” Senior vs Junior Residents In comparing senior (PGY 4-5, n ¼ 57) and junior (PGY 1-3, n ¼ 118) residents, senior residents were older (median age ¼ 28 [IQR: 26.5-29] vs 31 y [IQR: 30-32], p o 0.001) and more likely to have children (32% vs 9%, p o 0.001). They more commonly reported a lack of statistical knowledge and inability to recruit patients as moderate/extreme barriers to research pursuits (47% vs 34%; p ¼ 0.04, and
23% vs 8%; p o 0.01, respectively). Senior residents were more likely to have completed a research ethics board application (81% vs 58%, p ¼ 0.004). They more often disagreed that they participated in research for career advancement purposes (22% vs 7%, p ¼ 0.003) and that their research experience had made them “more likely to assist in future research projects” (30% vs 16%, p ¼ 0.03). There was no statistical difference in agreement with the statement that their research made them “more likely to initiate future research projects” when compared with junior trainees (35% vs 34%, p ¼ 0.44). Gender and Family Status There was no statistical difference between male (n ¼ 19) and female residents (n ¼ 156) regarding age, children,
TABLE 3. Resident Attitudes Regarding Research Experience, Research Environment, and Future Involvement
Attitudes regarding research experience/research environment “Resident research is a positive experience” “My training environment promotes research activity” “Rather than complete a research project, I would prefer to complete another educational activity” “I only do research because it is a mandatory part of my residency program” Attitudes regarding future involvement in research “I plan to do research when I am a staff physician” “Involvement in resident research has increased my desire to pursue research as a staff level physician”* “Involvement in resident research made me more likely to assist in future research projects”† “Involvement in resident research made me more likely to initiate future research projects”‡
Strongly Agree/ Agree
Neutral
Disagree/ Strongly Disagree
80 (46%) 90 (51%) 123 (70%)
62 (35%) 46 (26%) 32 (18%)
33 (19%) 39 (22%) 20 (11%)
106 (61%)
19 (11%)
50 (29%)
66 (38%) 54 (31%)
48 (27%) 39 (22%)
61 (35%) 71 (41%)
95 (54%)
32 (18%)
36 (21%)
60 (34%)
42 (24%)
60 (34%)
*11 (6%) Respondents answered “not applicable.” 12 (7%) Respondents answered “not applicable.” ‡ 23(13%) Respondents answered “not applicable.” †
Journal of Surgical Education Volume 72/Number 5 September/October 2015
839
prior research experience, career goals, reasons for participation in research, current research activities, perception of barriers to research, or questions related to attitudes regarding the effect of research on future practice. Residents with children (n ¼ 29) were older than those without (median age ¼ 31 y [IQR: 29-32] vs 28 [IQR: 2730], p o 0.001). Those with children more commonly reported publishing before residency (55% vs 34%, p ¼ 0.03). They were less likely to have applied for a grant (19% vs 41%, p ¼ 0.024) or have a research supervisor who published at least once per year (49% vs 79%, p ¼ 0.02). They reported a preference to develop their own research question rather than work on the one developed by their supervisor (10% vs 32%, p ¼ 0.003). Graduate Degree vs no Graduate Degree Residents with graduate degrees (Master’s degree or PhD, n ¼ 29) more often performed research in medical school (82% vs 62%, p ¼ 0.04), in undergraduate studies (83% vs 58%, p ¼ 0.01), and worked in research before residency (76% vs 34%, p o 0.001). Furthermore, they were more likely to report having applied for a grant (48% vs 18%, p o 0.001) and to report publishing in a peer-reviewed journal both before and during residency (83% vs 45%; p o 0.001, and 31% vs 17%; p ¼ 0.04, respectively) (Table 4). Residents without graduate degrees more often rated lack of training on research design as a moderate or extreme barrier (32% vs 7%, p ¼ 0.007). They more often reported being encouraged by a mentor (57% vs 38%, p ¼ 0.02). Residents with graduate degrees were more likely to report intention to undertake research as a staff physician (55% vs 34%, p ¼ 0.03) and a larger proportion agreed that they would assist with research projects in the future (72% vs 51%, p o 0.01). There was no difference in plans to initiate future research projects between these groups. Those with graduate degrees less often agreed with the statements “Rather than complete a research project, I would prefer to complete another educational activity” (52% vs 74%, p ¼ 0.03) and “I only do research because it is a mandatory part of my residency training” (38% vs 65%, p ¼ 0.01). Dedicated Program Research Time Attitudes of those who reported having dedicated research time, when compared with those without, were similar regarding most barriers. Those who reported having dedicated research time were more likely to report faculty support as a barrier to research (35 vs 17%, p o 0.01). Residents with dedicated research time were more likely to agree/strongly agree that their training environment promotes research (42% vs 7%, p o 0.01) and to agree/ strongly agree that they have supports for research at their institution (46% vs 7%, p ¼ 0.02). They more often agreed/strongly agreed that they would assist with research 840
projects in the future (42% vs 12%, p o 0.01). A greater proportion of those reporting dedicated research time agreed/strongly agreed that they only do research because it is a mandatory part of their residency (39% vs 15%, p o 0.01).
DISCUSSION Despite the inclusion of scholarly research activity as a requirement for successful completion of residency training in Ob/Gyn, resident attitudes toward this component of their training remains poorly characterized. The nature of this specialty, including its unique patient population, may render the resident research experience distinct from that of residents in other areas of medicine, including other surgical specialties. We therefore aimed to describe, as reported by Ob/Gyn residents, the extent of their involvement in research activities, motivators and barriers to their involvement, and the effect participating in research has had on their future career plans. We also collected data regarding pre-existing research experience (specifically through formal graduate degrees), seniority in residency training, gender, and family status to identify potentially influencing factors. The response rate of 36% is reasonable and higher than many other similarly designed studies (8%-47%)20,22-27 perhaps because we used 2 reminders and provided participation incentives. Perhaps the most striking findings of this study are that only half of Ob/Gyn residents felt that their training environment promoted research activities and that nearly one-fifth disagreed with the statement that “resident research is a positive experience.” Overall, 61% reported that they only participate in research because it is a mandatory component of their residency training and 70% reported that they would prefer to complete another educational activity—a rate comparable to that among anesthesiology residents.9 Clearly, our findings argue that there is considerable room for improvement in developing research curricula to better engage learners. More positive attitudes were observed among trainees with graduate degrees. This subset of trainees has arguably demonstrated a greater interest in research during medical school12; therefore, it is reasonable to assume that this interest continues into residency. In addition to suboptimal interest and enthusiasm among trainees, 2 leading reported barriers to resident research found in our study relate to time constraints. In fact, half of residents reported residency duties as representing an extreme barrier. Protected research time, either as a research rotation or an additional year dedicated to research, has been shown to improve research productivity in anesthesiology,9 internal medicine,28 emergency medicine,29 and general surgery.30 In our survey, provision of dedicated research time was associated with positive influences on
Journal of Surgical Education Volume 72/Number 5 September/October 2015
TABLE 4. Research Activities, Previous Experience and Attitudes Toward Research by Graduate Degree Status Master’s or PhD (n ¼ 29) Demographics Male gender Child/children Age (median) Senior resident (PGY 4-5) Previous research experience Worked in research before residency Research in medical school Research during undergraduate education Undergraduate thesis Published in a peer-reviewed journal before residency None Scholarly research activities Completed a grant application Completed a research ethics board application Completed a research methods course Published in a peer-reviewed journal during residency Attitudes toward research activities Agree or strongly agree with the statements: “Rather than complete a research project, I would prefer to spend time completing another educational activity” “I only do research because it is a mandatory part of my residency training” Agree or strongly agree that involvement in resident research has made them more likely to: “Initiate future research activities” “Assist in future research activities”
attitudes toward research including feeling that they were supported at their institution and anticipation that they would assist with research in the future. Currently, however, rotations dedicated to research are generally considered “selectives” by Canadian accrediting bodies with no mandate for protected time.1 Structured research mentorship31 or appointment of a resident research director or both32 are also potential strategies for provision of research support, both of which have been shown to improve resident research productivity. The optimal approach likely varies by institute and specialty. For instance, Fischer and Cation33 reported that having an appointed resident research director had a greater effect on research productivity than protected resident research time for their internal medicine program. However, in our survey, 97% of residents identified time constraints owing to residency duties as a barrier compared with only 59% who identified lack of faculty support/mentorship. Lack of statistical knowledge was also considered a major barrier to research activity among residents, though less so for those with graduate degrees. Interestingly, senior residents (PGY 4-5) more commonly reported lack of statistical knowledge as a barrier, perhaps because juniors were not yet in the analysis phase of their research. In a survey of American and Canadian Ob/Gyn program directors regarding research education curricula, 58% reported having a designated biostatistician and 47% had didactic sessions on
No Graduate Degree (n ¼ 146)
pValue
3 3 28 9
(10%) (10%) (IQR: 27-31) (31%)
15 26 29 48
(10%) (18%) (IQR: 27-31) (32%)
0.99 0.32 0.89 0.84
22 24 24 15 24 2
(76%) (83%) (83%) (52%) (83%) (7%)
49 92 85 48 66 22
(34%) (63%) (58%) (33%) (45%) (15%)
o0.001 0.04 0.01 0.05 o0.001 0.24
14 22 17 9
(48%) (75%) (59%) (31%)
27 93 90 25
(19%) (64%) (61%) (17%)
o0.001 0.20 0.76 0.04
15 (52%)
108 (74%)
0.04
11 (32%)
95 (65%)
0.01
11(38%) 21 (72%)
48(35%) 74 (50%)
0.19 0.008
biostatistics and epidemiology.15 Attendance at a research methodology course has been shown to improve research productivity among surgical residents.34 Instituting and preserving such support systems as well as ensuring resident awareness of local resources for research assistance may aid them in their research pursuits. Almost half of our survey respondents listed lack of funding as a barrier to research, yet only 23% had completed a grant proposal. This raises the questions of whether grants are directed to areas of resident research and whether residents feel qualified and supported in applying for funding. Levine et al.35 found that having funding designated for resident scholarship was associated with decreased odds of a program being “cited for lack of scholarship activity.” Similarly, a study of Ob/Gyn resident research projects attributed increased frequency of research publications and presentations at national meetings in part to the initiation of an endowment fund.36 The main strengths of our study include that it represents a national sampling of residents and that it used a comprehensive survey regarding motivators, research activities (both pre-existing and during residency), and perceived barriers to research endeavors, thereby providing insight into potential targets for program development. Limitations of our study include the self-reported nature of the data and potential for responder bias, and reliance on program administrators to forward the survey. The survey req-
Journal of Surgical Education Volume 72/Number 5 September/October 2015
841
uested self-reported information regarding publications, presentations, and time spent on research pursuits. Independent verification of this data was not possible. The number of residents who received and read the invitation to complete the survey is not known as the study personal did not receive “failure to deliver” e-mail responses directly. Response rates were based on number of active residents as declared by program administrators. Small monetary participation incentives have been shown to reduce nonresponse error among survey participants,37 especially in studies with topic bias.38 Incentives were used in our study, particularly to encourage participation among individuals who were not highly involved or interested in research pursuits; however, the success of this approach is not known.
3. Takahashi O, Ohde S, Jacobs JL, Tokuda Y, Omata F,
CONCLUSIONS
7. Hsieh H, Paquette F, Fraser SA, et al. Formal research
Leading barriers to Ob/Gyn resident research pursuits, as reported by the residents themselves, include lack of time owing to clinical duties, lack of time owing to personal duties, and lack of understanding of statistical principles. Our data suggest that strategies to improve resident research involvement should include protected research time and statistical support with consideration given to formal research mentorship and appointment of a resident research director. Many residents do not feel that their training environment promotes research and one-fifth of residents did not feel that residency research was a positive experience. Further work is needed to evaluate whether a change in research curricula can improve the residency research experience.
Fukui T. Residents’ experience of scholarly activities is associated with higher satisfaction with residency training. J Gen Intern Med. 2009;24(6):716-720. 4. Toledo-Pereyra LH. Becoming a surgical scholar.
J Invest Surg. 2011;24(4):139-140. 5. Turnberg LA. The place of research in the training of
NHS consultant physicians. J R Coll Physicians Lond. 1993;27(4):403-404. 6. Dodge JE, Chiu HH, Fung S, Rosen BP. Multicentre
study on factors affecting the gynaecologic oncology career choice of canadian residents in obstetrics and gynaecology. J Obstet Gynaecol Can. 2010;32(8): 780-793. training during surgical residency: scaffolding for academic success. Am J Surg. 2014;207(1):141-145. 8. 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(4):366-369. 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(3):859-864. 10. Ullrich N, Botelho CA, Hibberd P, Bernstein HH.
Research during pediatric residency: predictors and resident-determined influences. Acad Med. 2003;78 (12):1253-1258.
ACKNOWLEDGMENTS
11. Salgueira A, Costa P, Goncalves M, Magalhaes E,
We are grateful to our panel of experts (Drs. Jay Baltz, Andrée Gruslin, and Tien Le) for their assistance with survey questionnaire development, to the Academy for Innovation in Medical Education for research funding support, and to the Ottawa Hospital Research Institute Methods Centre for assistance with statistical analysis.
12. Siemens DR, Punnen S, Wong J, Kanji N. A survey
Costa MJ. Individual characteristics and student’s engagement in scientific research: a cross-sectional study. BMC Med Educ. 2012;12:95. on the attitudes towards research in medical school. BMC Med Educ. 2010;10:4. 13. Rayburn WF, Gant NF, Gilstrap LC, Elwell EC,
Williams SB. Pursuit of accredited subspecialties by graduating residents in obstetrics and gynecology, 2000-2012. Obstet Gynecol. 2012;120(3):619-625.
REFERENCES 1. Canada RCoPaSo. Specialty Training Requirements in
Obstetrics and Gynecology. Available at: 〈http://www. royalcollege.ca/rc/faces/oracle/webcenter/portalapp/ pages〉; 2013. Accessed 08.13.
2. Smith GN, McNamara H, Bessette P, et al. Resident
research training objectives and requirements of the association of academic professionals in obstetrics and gynaecology. J Obstet Gynaecol Can. 2011;33(10): 1044-1046. 842
14. Gill S, Levin A, Djurdjev O, Yoshida EM. Obstacles
to residents’ conducting research and predictors of publication. Acad Med. 2001;76(5):477. 15. Kenton K, Brubaker L. Research education in obstet-
rics and gynecology: how are we doing? Am J Obstet Gynecol. 2007;197(5):532.e1-532.e4. 16. Svider PF, D’Aguillo CM, White PE, et al. Gender
differences in successful National Institutes of Health
Journal of Surgical Education Volume 72/Number 5 September/October 2015
funding in ophthalmology. J Surg Educ. 2014;71(5): 680-688. 17. Sexton KW, Hocking KM, Wise E, et al. Women in
academic surgery: the pipeline is busted. J Surg Educ. 2012;69(1):84-90. 18. Reid R, Susic D, Pathirana S, Tracy S, Welsh AW.
The ethics of obtaining consent in labour for research. Aust N Z J Obstet Gynaecol. 2011;51(6):485-492. 19. Ching SL, Gates EA, Robertson PA. Factors influenc-
ing obstetric and gynecologic patients’ decisions toward medical student involvement in the outpatient setting. Am J Obstet Gynecol. 2000;182(6):1429-1432. 20. Oakley SH, Crisp CC, Estanol MV, Fellner AN,
Kleeman SD, Pauls RN. Attitudes and compliance with research requirements in OB/GYN residencies: a national survey. Gynecol Obstet Invest. 2013;75(4): 275-280. 21. Artino AR Jr, Gehlbach H, Durning SJ. AM last page:
avoiding five common pitfalls of survey design. Acad Med. 2011;86(10):1327.
22. Antosh DD, Gutman RE, Iglesia CB, Sokol AI, Park
AJ. Resident opinions on vaginal hysterectomy training. Female Pelvic Med Reconstr Surg. 2011;17(6): 314-317. 23. Jacob KA, Bell J, Francis S. Resident training in female
sexual dysfunction: a comparison of urology and obstetrics and gynecology programs. Female Pelvic Med Reconstr Surg. 2011;17(5):238-241. 24. Chapman SJ, Hakeem AR, Marangoni G, Raj Prasad
K. How can we enhance undergraduate medical training in the operating room? A survey of student attitudes and opinions. J Surg Educ. 2013;70(3): 326-333. 25. Ivanovic J, Maziak DE, Gilbert S, et al. Assessing the
preferences of surgical residents toward laparoscopic simulation training: a resident survey. J Surg Educ. 2014;71(5):727-733. 28. Hepburn MJ, Battafarano DF, Enzenauer RJ, et al.
Increasing resident research in a military internal medicine program. Mil Med. 2003;168(4):341-345. 29. 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(4): 356-359. 30. Thomas JB, Cofer JB, Lewis PL, Burns RP. Clinical
research during surgery residency: the Chattanooga approach. Curr Surg. 2000;57(2):135-139. 31. Ogunyemi D, Solnik MJ, Alexander C, Fong A, Azziz
R. Promoting residents’ professional development and academic productivity using a structured faculty mentoring program. Teach Learn Med. 2010;22(2):93-96. 32. Durning SJ, Cation LJ, Ender PT, Gutierrez-Nunez
JJ. A resident research director can improve internal medicine resident research productivity. Teach Learn Med. 2004;16(3):279-283. 33. Fischer JL, Cation LJ. Impact of a residency research
program on research activity, faculty involvement, and institutional cost. Teach Learn Med. 2005;17(2): 159-165. 34. Farrokhyar F, Amin N, Dath D, et al. Impact of the
surgical research methodology program on surgical residents’ research profiles. J Surg Educ. 2014;71(4): 513-520. 35. Levine RB, Hebert RS, Wright SM. Factors associated
with citation of internal medicine residency programs for lack of scholarly activity. Teach Learn Med. 2005;17(4):328-331.
status of thoracic surgical research and quality improvement programs: a survey of the members of the canadian association of thoracic surgeons. J Surg Educ. 2011;68(4):258-265.
36. Morrison JC, Meeks GR, Martin JN Jr, Cowan BD,
26. Kroft J, Moody JRK, Lee P. Canadian Hysterectomy
37. Adua L, Sharp JS. Examining survey participation and
Educational Experience: survey of recent graduates in obstetrics and gynecology. J Minim Invasive Gynecol. 2011;18(4):438-444.
response quality: the significance of topic salience and incentives. Surv Methodol. 2010;36(1):95-109.
27. Shetty S, Zevin B, Grantcharov TP, Roberts KE,
Duffy AJ. Perceptions, training experiences, and
Whitworth NS, Wiser WL. Resident research projects: frequency of presentation and publication in a national forum. Am J Obstet Gynecol. 1994;170(3):777-781.
38. Groves RM, Presser S, Dipko S. The role of
topic interest in survey participation decisions. Public Opin Q. 2004;68(1):2-31.
SUPPLEMENTARY MATERIALS Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2015.02.007. Journal of Surgical Education Volume 72/Number 5 September/October 2015
843
