Formal Research Training – An Essential Aspect for Surgical Residency?

Working as a physician in the 21st century is clearly a different endeavor compared to 50 or 100 years ago. Automation and digitalization in every part of modern work have fundamentally changed the medical sciences and clinical environments. The rise of artificial intelligence (AI) and deep machine learning will likely transform patient care and medical research in the near future. A recent study published in Nature Medicine showed that AI was as effective as junior pediatricians in detecting common pediatric diseases.1 In surgery, it is still unclear how far AI will be able to refine, accelerate, or even replace surgeons in their specialized fields. Albert Einstein once said: “Imagination is more important than knowledge. For knowledge is limited […]”. In the context of this modern technological revolution, imagination, and constant reinvention as surgeons seem more important than before. To proactively design the future of surgery, it is essential that surgeons become key players in novel and high-quality research. Historically, surgeons have been combining both clinical and research activities since the 1800s, as suggested by the term “surgeon-scientist.” Unfortunately, the quality of surgical research seems to be declining. In the New England Journal of Medicine, the proportion of surgical papers on the overall number of publications in the journal has been dropping dramatically since 1952.2 Even more concerning is the apparent shortage of young surgeons to design and conduct original research.3 A recent Nature editorial urged more surgeons to perform basic science as a response to a report that indicated that the number of surgeon-scientists has dramatically been decreasing.4,5 These negative developments in surgical research seem hazardous and conflicting with the upcoming drastic changes and innovations required to maintain a high level of performance in modern academic surgery. Woldu et al, consequently asked whether the surgeon-scientist is a dying breed.6 In this context, it is particularly unfortunate that the interest in research seems to decrease among young surgeons, resulting in the “extinction of surgeon-scientists.”7 Recently, the Basic Science Committee of the Society of University Surgeons published a roadmap to encourage and guide the next generation of surgeon-scientists towards their academic career.8 Doing a research fellowship can be an essential step on this roadmap for aspiring surgeon-scientists. Here we aimed to highlight the benefits of a research fellowship and the advantages it holds for an academic surgical career. Whether the aim of the trainee is to become a surgeon-scientist or not, performing a research fellowship will impact and strengthen the 3 pillars of a modern academic surgeon: clinical practice, research, and teaching. Individual outcomes of formal research training among general surgeons show a strong association of research time during residency and objective markers of long-term academic success.9 Surgeons that performed 1 year of research training had higher h-indices and were more likely to obtain National Institutes of Health funding later in their careers.9 Bobian et al reported that otolaryngology surgeons who had research training were more likely to achieve higher academic ranks, whereas clinical fellowships did not show this association.10 It seems intuitive that surgeons who perform research training are more likely to thrive in academic environments. Dedicated research training promotes research productivity and output. Surgeons that performed a 1-year research training had more first-author publications during residency, which objectifies their commitment to research and their ability to lead a project to completion.9 Being “extracted” from a clinical setting and put into a scientific environment might be an initially stressful and frustrating experience for a trainee but can eventually promote a unique and precious “out-of-the-box” thinking attitude. Research fellowships are often the trainee's first interaction with research, especially in Europe where medical students do not usually perform an undergraduate degree before entering medical school. Such research experiences prepare young surgeons for their work in academic centers. Given the worldwide ongoing centralization into large academic centers, young surgeons will benefit from such preparation. Research training will teach young surgeons how to distinguish low-quality from high-quality scientific work, how to read, evaluate, and criticize the scientific literature and how to put different scientific methodologies into perspective. Moreover, this experience will teach surgeons how to plan and manage projects and to understand what it takes to complete a project within a certain timeframe. Some academic centers offer opportunities to enroll into programs leading to a secondary degree such as the Doctorate, Master of Science, Master of Public Health, Master of Science in Public Health, or Master of Business Administration. Residents involved in such programs with coursework would receive formal research training on various aspects of research, such as methodology, ethics, and grant writing The impact of a research fellowship on the clinical mindset and performance – although difficult to objectify – can be significant. Dedicated time for research is the ideal ground for boosting creativity that can later be applied to both scientific and clinical practice. The time and freedom required for creativity will render visionary and innovative strategic thinking. This time and freedom are not always available in a busy clinical environment. A more inquisitive mindset will help to shift one's perspective from the diagnosis and management of a disease towards questioning the underlying pathogenesis, facilitating bedside to bench research, as a first essential step to translate results from bench to bedside. Moreover, the extra time during training without calls and night shifts allows for new information to be processed and stored properly. To memorize knowledge and recall when necessary we need time. The opportunity to do exactly this and the freedom to take some time to reflect will likely enhance quality of life during those years.11 Throughout a research fellowship, trainees will be interacting with scientists, biologists, and students with different backgrounds. Whereas it is well-known that physicians, and even more so surgeons, tend to evolve in a tight community of similar personalities with similar backgrounds and training, a diverse research experience provides an ideal environment to improve communication skills. Clear communication is crucial in medicine. Patient outcomes depend on exact communication between physicians, nurses, patients, and caregivers. Also, good interaction can enhance work satisfaction among the involved professionals. It is essential for effective communication to express thoughts precisely and clearly. During research training, residents learn how to express their thoughts clearly and communicate complex data in an understandable way. For instance, scientific abstract and manuscript writing requires precise and concise summarizing of research findings. The preparation of a scientific presentation will train the resident to introduce their topic in a structured and logical way. Furthermore, learning how to present results from fundamental research will clearly enhance teaching skills. A scientific discussion educates trainees to defend their opinion but also to consider other valuable aspects. This enhances critical thinking skills which are important to acquire during research time. The constant interaction with other researchers fosters scientific thinking, that can be used for research design and hypothesis. The underlying scientific motto postulated by Karl Popper in his “Logic of Scientific Discovery” was the attempt to falsify one's own hypothesis. This constant reflection on hypothesis, results, and their interpretation will practice critical thinking, that in turn enables young surgeons to question dogmas in the clinical arena and position them to develop innovative strategies to challenge these dogmas. Another positive effect of formal research training is access to the international surgical community. Meetings at scientific conferences not only provide young academic surgeons with the state-of-the-art knowledge in their field, but also nourishes relationships with other academic surgeons worldwide. Once introduced to the international scientific community, young surgeons will become part of this community which can boost their intrinsic motivation. This can broaden their horizon as a surgeon and a person and put opinions into perspective. These benefits do not apply only to the trainee, but also to the institutions and training programs. The reputation of an academic center with high quality research will help attract future students, residents, and fellows, but also maintain a certain level of expertise and expectation, resulting in further expansion of the academic mission. These institutions should aim to develop a culture where scientific activity is the “gold-standard” and not the exception. Therefore, dedicated and protected research time is essential and young academics who undergo research training are more likely to support this approach. Lifelong personal relations with mentors within academic institutions can foster ongoing scientific and personal mentorship. It is widely accepted that one requirement for a successful career in medicine is mentorship.8 During a research fellowship it is likely that, one will find a lifelong mentor with substantial experience to support and guide the resident's trajectory in a surgical career. Moreover, extra time for personal development under directly mentored supervision will not only help to become a better researcher, but also enhance skills like public speaking, writing, innovative thinking, and networking. In line with this, Mansukhani et al argue that the years spent in the laboratory should be rebranded as personal development time.12 Whereas most countries are aiming towards standardized surgical training programs, a research fellowship is the ideal time for a resident to enjoy some freedom in training and self-management. This may lead to discover a new interest for yet unexplored domains during the often rigid and standardized clinical training. Although in the US and Canada research fellowships are often undertaken before or during general surgical residency, this is still rather an exception for trainees in other countries. In the US and Canada, research fellowships help applicants to obtain a position for residency or clinical fellowship which is likely why there is more request to do research during their training. In most European countries, where surgeons often times start a subspecialty without prior training in general surgery, there is no such incentive to conduct research training. Another aspect concerns the costs of a formal research training program for residents and their absence in clinical training during that time. Who will pay or compensate for it? We believe that if we want to strengthen and improve academic surgery, we have to advocate for funding for young academic surgeons to participate in established research programs. As academic surgeons, we have to participate in the decision making on the allocation of research funds and be present in the respective review committees. Also, access to dedicated research time has to be without barriers for all academic surgeons. Equity, diversity, and inclusion need to be promoted in terms of opportunities to collaborate or issues in balancing family and work life. If we want to enhance surgical research performance, we have to guarantee equal opportunity to recruit the best possible faculty into academic surgery. Now that the benefits of performing a research fellowship have been well established, another crucial question is the timing of such an experience. We believe that early research exposure is essential to develop the abovementioned skills necessary for high quality research. A formal training early during residency will not only enhance the interest for the specialty but will allow the establishment of a critical and scientific mindset that the resident will be able to benefit from during his/her residency. More than ever, it is now undeniable that surgeons should invest more in (basic) science – a formal research training such as a research fellowship is the best starting point to do exactly this.

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