Research — An Important Skill?
The Accreditation Council for Graduate Medical Education (ACGME) states that a medical “curriculum must advance residents' knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.” The aim is to help residents develop lifelong learning and the skills necessary to engage in evidence-based clinical decision-making. The ability to understand, analyze, and critique research articles is considered an important part of training. The ACGME asserts that residents should participate in scholarly activity and the sponsoring program should allocate resources to facilitate resident involvement. Research experience is an invaluable skill for emergency medicine residents and physicians.
Residency programs promote scholarly activities through a number of means. Often the curriculum includes conference presentations on evidence-based medicine. Journal clubs are another forum for presentations, research, and evidence-based medicine discussions. Although the ACGME promotes scholarly activity, the specific form taken by such activity varies across graduate medical programs. Whether the end product is a case report, a rejected abstract, or an impactful publication in a prestigious journal, there are inherent skills to be gained from just the process of research. Residents learn how to perform a literature review, formulate a hypothesis, develop study methods, analyze and interpret data, and present the results.
Residents choose to perform research for a variety of reasons. Some, perhaps inspired by a mentor or prior success, are truly interested in research. Others, however, may pursue research because it is perceived as a valuable experience. Some have no interest whatsoever in research and will not pursue any beyond what is required. Performing research during residency presents its challenges. The task to complete a project from conception to publication takes dedication, mentoring, support, and some luck. To better understand barriers that residents experience when pursuing research or deciding whether or not to do so, the EMRA research committee performed a survey on the topic.
We distributed a survey to members of the Emergency Medicine Residents' Association in December 2014. Out of the 1,668 residents to whom we sent the survey, 166 completed it. The majority (60%) of the respondents were male, and primarily in their first two years of residency – 32% post graduate year (PGY) 1 residents, 23% PGY2, 20% PGY3, 11% PGY4, and 13% fellows/others. Geographically, there were higher proportions of respondents from the Northeast (40%) and Midwest (31%). Those who completed the survey reported a decrease in research experience during residency; 84% had research experience prior to residency, compared to 75% during residency. Correlating this finding, 53% of respondents had one or more publications prior to residency, compared to 18% during residency. Even though 83% of residents expressed interest in research, and 88% reported having adequate support from their residency programs, there were several barriers identified.
Forty-nine percent of responding residents reported they did not have sufficient time during residency to pursue research, and 66% expressed that they wanted more time. Other barriers were a lack of financial support (49%), attending/research mentor support (42%), or lack of institutional support (40%). However, less than one percent reported that research was discouraged at their institution.
Qualitative responses further described the lack of institutional support. All research projects must have Institutional Review Board (IRB) review and approval. Respondents reported not having enough guidance for IRB submission and support for research methods and statistical analysis. Residents described the IRB submission as “absurdly laborious,” and “unwieldy”¦ which discourages research.” In addition, a lack of mentoring in methods or statistical guidance presented a challenge. Residents described, “not enough support in terms of understanding biostatistics or helping those who have no idea how to set up a research design” and, “not enough teaching about research methodology.”
Although we distributed our survey to EMRA members nation-wide, the respondents represent a small proportion of total residents. Given the high numbers of respondents who reported having prior research experience, it is possible that those who completed the survey did so because they have a particular interest in research. Thus our survey results may not be appropriately generalized to residents with less research interest.
There was a decrease in publication success during residency. While a significant majority of residents had publication success before residency, only a fifth experienced success as residents. Lack of success with publication can be discouraging. It appears there is discrepancy between perception of institutional support and actual support. Close to 90% of residents reported having adequate support from their program, but deficits in institutional support were also highly reported.
The most commonly reported barrier to research was time.
This was somewhat anticipated, given the clinical time demands of residency training. One resident commented, “a three-year residency barely provides enough time to learn clinical medicine; to really improve research opportunities and interest, residency really needs to be four years.” There has been a recent trend for residency programs to transition to four-year programs. Overall, four-year residency programs tend to have more elective time. Efficient time management during residency and collaboration with support staff, colleagues, and medical students on a project are important tools for success.
Even though financial support may be a challenge, there are funding opportunities are available from the Emergency Medicine Foundation (EMF) and EMRA. EMF offers grants of up to $5,000 to residents and $2,400 for medical students. EMRA offers local action grants and research grants of $1,000. Local action grants are designed for projects aimed at community outreach. Beyond these funding opportunities, there may be funding opportunities within local institutions and national foundations.
Identifying a capable research mentor is important to developing a successful project. The surveyed showed that at times, “faculty members are too busy to keep up with (resident) projects; to have it done and published in time.” Residents are more likely to achieve success if they find a mentor with a proven track record of mentoring. If unable to find a mentor or one with a compatible interest, it may be reasonable to contact the program directors, since they may be able to direct the resident to someone outside of the program.
There are opportunities for improvement in institutional support. Institutional Review Board (IRB) submission can be time-consuming. Research projects with any risk to patients need to be fully reviewed by the research ethics committee. Given the time constraints of residency, an alternative option would be to pursue retrospective chart reviews so that fewer ethical issues arise during the IRB review process. The main requirement in these studies is just to remove all identifying patient information to ensure confidentiality. Such studies are eligible for exemption and can be approved more quickly, since they do not need to be reviewed by the entire IRB.
Statistical and research methods present a barrier to successful completion of research. Statistical software such as STATA and SAS can be quite powerful, yet difficult to use for researchers without prior training. Moreover, such software is often expensive. Residency programs affiliated with academic institutions may have access to software and thus make research less expensive for residents. An alternative and capable program that is available for free download is Epi-Info, developed by the Centers for Disease Control and Prevention. The program includes data management and statistical functions.3 Another option for statistics computation is the online statistical tool Open-Epi.4
Many residents express strong interest in pursuing research, and some meet success despite competing responsibilities of clinical education and other residency requirements. Even though a large proportion of residents report strong research support from their programs, it appears there are deficits in support for funding, statistics, and mentoring for research methods.
Contributions to this article made possible through Josh Bucher, MD and the EMRA Research Committee.