Publications by Graduating Residents: Don’t Turn Off the Alarm Clock Yet

In this issue of Anesthesia & Analgesia, a report of the current state of scholarly productivity by residents graduating from Accreditation Council for Graduate Medical Education approved anesthesiology residencies is presented.1 The authors found a progressive increase in scholarly activity by recent graduates in anesthesiology during a 10-year period, 14.9%–29.3% of residents with a PubMed publication. These results are especially encouraging given the editorial published in 2006 (the first year examined in the study under consideration) in which a wake-up call was issued to physician-scientists to increase research and publications in anesthesiology.2 While the editorial focused primarily on National Institutes of Health funding, there was a tenor in the editorial concerning a decrease in research, by both physician-investigators and resident physicians. While the current study does not allow one to determine whether the physician-investigators heeded the wake-up call, the increase in publications by graduating residents intimates that resident physicians may have. Before the alarm clock is turned off, all aspects of resident publications as well as resident research must be examined to truly understand the current status. There is a greater focus on research by the Accreditation Council for Graduate Medical Education. According to Dr Reves who provided the 45th Rovenstine Lecture in 2007, the lack of resident research is because of the lack of requirement by the Accreditation Council for Graduate Medical Education; the only means to improve research is to make it mandatory.3 This lack of requirement for research from the Accreditation Council for Graduate Medical Education has been modified. The Common Program Requirements (applies to all residencies) now require an understanding of the basic principles of research, including the explanation and application of research.4 While an understanding of the basics of research is required of all residencies, anesthesiology has further specified the requirement by mandating all residents complete an academic assignment that is suitable for presentation at a national meeting or for publication. The success of this requirement is debatable as one of the most frequent citations issued by the Anesthesiology Review Committee is for resident scholarly activity (communication from Society of Academic Associations of Anesthesiology & Perioperative Medicine Annual Meeting 2018). This discrepancy between the results of the current study and the frequency of citations for resident scholarly activity may be a result of failure of programs to report resident publications; this explanation is unlikely given that program directors prefer to avoid citations. Although resident scholarly activity does not have to be research with publication according to the Accreditation Council for Graduate Medical Education with presentations at meetings also counting toward scholarly activity requirement, there may be more to the explanation for this difference. Several residency programs have developed curriculums to address the program requirements for research as well as to improve the recruitment of academic anesthesiologists. In a survey sent to 131 core program directors, 91 programs responded and of these programs, 31 had a structured research education program.5 This publication occurred in 2013, the midway point of the current study, and may provide a insight into the results. Of the programs with a research curriculum embedded in the residency, there was a requirement for resident participation in a research project and for learning about presenting and writing scholarly material. Of the programs with a research curriculum, 12 of the programs were successful with success defined as having >20% of graduating residents with a publication. Furthermore, there was no difference in success if the research rotation was >2 months as compared to <2 months. There is some suggestion that these research tracks within residency may account for the increase in publications by residents. When an article is published, the ranking of the authors is important. The first author is assumed to be individual who contributed the most to the study while the last author is assumed to be the driving force or mentor.6 Authors in positions other the first and last usually indicate those who participated in the research but did not have a major contribution. In the current study, the percentage of publications with graduating residents as first author and as last author declined over the 10-year period, 46.7%–36.23% and 25.26%–8.31%, respectively. As such, the increase in publications by graduating residents was a result of resident participation in research as compared to contributing significantly or being involved in the design or execution of the project. Such participation does contribution to being listed as an author, thus fulfilling the Accreditation Council for Graduate Medical Education requirement. However, mere participation in research does not meet the original goal of the research track within training, which was to instill a spirit of inquiry within a resident regarding research. The motivation for publication by a resident in the United States has not been determined. The excitement of having one’s study published generally encourages further participation in research. While the motivation for residents’ participation in research has not been assessed in the United States, it has been done in Canada. In Canada, the majority of residents did not think research should be mandatory with a discrepancy between the viewpoint of the program director and the resident.7 Program directors did not feel that time was a barrier while residents felt schedule conflicts and lack of protected research time to be top barriers to conducting research. If left to the residents’ discretion, they would prefer to spend their time learning transesophageal echocardiography as compared to completing a research project. If this viewpoint applies to residents in Accreditation Council for Graduate Medical Education–accredited residencies in the United States, it is not surprising that the percentage of first and last authorships did decrease with time while middle authorship increased. The current study actually may be more optimistic than the results suggest. The authors only investigated whether there was a link between graduates from residency and publication in anesthesiology journals. Any work not published in a non-anesthesiology journal would be missed. The greater optimism is supported by a study from Academic Medicine. This study examined publications within the journal from medical students or residents during a 15-year period.8 The intent of the study (which did not include a resident) was to determine the impact of education tracks and of emphasis on research within medical school and residency, using the surrogate of publication within the journal as a marker of success. During this time period, the percentage of publications of any type with either medical student or resident authors increased from 9.4% in 2002 to 18.8% in 2016. The majority of publications were original research as compared to medical humanities or editorials. It seems that the results of this study mirror the current study. There are other aspects which further validate the results of the study as compared to the number of citations concerning resident scholarly activity from the Anesthesiology Review Committee. There exists a competition for fellowships in pain medicine. According to the National Resident Matching Program, in 2017, there were 335 positions within the match for pain medicine.9 For these positions, there were 437 applicants, meaning that at least 102 applicants would go unmatched. The final outcome for 2017 was that 105 applicants did not successfully match into a Pain Medicine fellowship. The statistics for this match is that 1 of 4 applicants will not be successful in obtaining a fellowship. Given the similarity of training for the core residency in anesthesiology and the refusal of the American Board of Anesthesiology to release scores for the Basic Examination (first of 3 certifying exams that is taken during the second year of residency), fellowships rely on in-training examination scores as well as scholarly activity during residency to assist with decision process. As such, one component of the increase may be a result of residents with an interest in fellowship in pain medicine trying to improve their candidacy through research and publication. Of course, the increase in publication may be due to the recruitment of medical students who have previously published. There is some suggestion that the increase in resident publications may simply be a result of recruiting individuals whose passion for research developed in medical school. More medical students entering residency have performed research before entering residency. The Association of American Medical Colleges Graduation Questionnaire reported that student authors in research submitted for publication have increased from 32.9% in 2002 to 46.5% in 2016.10 The Foundation for Anesthesia Education and Research Medical Student Anesthesia Research Fellowship is an 8-week program that matches second-year medical students with anesthesiologists engaged in research. From 2005 to 2012, there were 346 students who participated in this opportunity.11 Of the students who had data about matched residencies available, 58% chose to pursue a career in anesthesiology. Of the projects worked on during the fellowship, 42% were subsequently published. It is surprising that the success of residents does not extend to faculty and program directors. Program directors in anesthesiology are less likely to have prior or active National Institutes of Health funding and fewer PubMed citations as compared to program directors in surgery.12 The number of publications for program directors in anesthesiology was 43% that of surgery program directors. The concern of the lower percentage of publications for program directors is that this difference may reflect a weak academic environment in anesthesiology. Surgery residents typically spend some time during residency in research as compared to anesthesiology. In fact, only 1 fellowship, obstetric anesthesiology, has dedicated time for research during training. Also program directors are role models for residents; it appears that residents are actually better than the program director in regard to publications. Despite an Accreditation Council for Graduate Medical Education program requirement for scholarly activity, the faculty in anesthesiology is not doing any better than the program director. Using a database from the American Association of Medical Colleges, 6143 faculties within academic programs were identified.13 Of these faculty, 8521 PubMed publications were published. Although these results suggest that each faculty member published an average of 1.3 publications, only 37% of the faculty accounted for these publications. As such, the majority of faculty have not published a manuscript between 2006 and 2008. Of those faculty publishing, professors were more likely to have a publication as compared to an instructor. Publications serve as a marker for academics. It is an easily measured indicator of the success of the scholarly activity within a residency. In 1990, Boyer broadened the meaning of scholarship by outlining 4 domains: the scholarship of discovery, the scholarship of integration, the scholarship of application, and the scholarship of teaching.14 This expanded definition was well received by the academic community and also provided a challenge in proving quality to each aspect. Standards were advocated for excellence in scholarship: clear goals, adequately prepared, use appropriate methods, achieve outstanding results, communicate effectively and reflectively critique of the work. This approach broadens the definition of scholarship and makes publication an aspect of scholarship as compared to the sole definition. In response to the broadened definition, the Accreditation Council for Graduate Medical Education has refined the concept of scholarly activity. The change in definition is more aligned to the broadened definition from Boyer, including presentations, grand rounds, chapters, and service on national committees. It is interesting that the Accreditation Council for Graduate Medical Education is allowing each specialty the option of choosing whether to require peer-reviewed publication. There are certain take-home messages that this article either states or hints. Scholarly activity is important for the specialty and should begin in residency. Residents currently participate in research and their participation must be elevated to a more active engagement as compared to simple participation. While a curriculum in research may be helpful, mentorship from faculty is critical. There are not many faculty members engaging in publication; there are numerous faculties engaging in scholarly activity as defined by Boyer. Publications and research ultimately affect clinical care; it is this knowledge that provides the motivation for achieving the goal of publishing. The wake-up call for graduating residents has been heard; it just isn’t time to turn off the alarm clock. DISCLOSURES Name: Robert Gaiser, MD, MSEd, FASA. Contribution: This author organized and wrote the editorial. Conflicts of Interest:R. Gaiser is the Director for the American Board of Anesthesiology. This manuscript was handled by: Edward C. Nemergut, MD.

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