timulating Resident Research in a Generalurgery Residency Community Program
oann Lohr, MD,* J. Michael Smith, MD,* Richard Welling, MD,* Amy Engel, MA,†im Hasselfeld, BS,† and Joy Rusche†
Department of Surgery, Good Samaritan Hospital; †E. Kenneth Hatton, MD, Institute for Research and
ducation, Cincinnati, Ohio
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BJECTIVE: Resident research teams were established at thisommunity hospital in the 1997 academic year. Research pro-uctivity, including publications and presentations in the yearsefore establishing research teams and the 8 years subsequent tostablishment of research teams with faculty mentors, waseviewed.
ETHODS: Each team is supported by a research specialistho provides assistance with project design, data evaluation,
tatistical analysis, manuscript editing, and preparation of re-earch presentations. Every resident is assigned to a researcheam that meets monthly. The teams consist of a 4th- or 5th-ear resident, 2nd- or 3rd-year resident, surgical intern, researcheam mentor, and research specialist. The resident is required toe an active contributing co-investigator on 1 team project perear, contributing to the development and performance of thetudy, participating in writing the manuscript, and must be ableo defend the study. By the end of the third year, the resident isequired to complete 1 individual project that is submitted tohe postgraduate competition for residents. In addition, a com-leted manuscript must be ready to submit to a peer-reviewed
ournal. Promotion can be denied if the appropriate time hasot been devoted to research. Minimum completion require-ents include a case report and a presentation at a national or
egional meeting. The research registry was reviewed for allresentations and publications given by the surgical residentsuring the 8 years before the teams were established and the 8ears after the teams were formed.
ESULTS: In the 8 years before the establishment of researcheams, 60 papers were published. After the establishment ofesearch teams, 77 papers were published. During the 8 yearsefore research teams were being established, 69 presentationsere given. During the subsequent 8 years with the use ofentoring and research teams, 92 presentations were given.
orrespondence: Inquiries to Joann Lohr, MD, c/o Amy Engel, Hatton Institute, Good
cholarly activity has frequently been cited by the residencyeview committee (RRC) at the time of accreditation reviewsor general surgery programs and has been especially problem-tic in the community setting. This study was undertaken tovaluate the establishment of research teams on research pro-uctivity and activity at Good Samaritan Hospital, a commu-ity-based general surgery residency fully-accredited under theRC.
ETHOD
he Good Samaritan Hospital General Surgery program wasstablished in 1954 and is fully accredited. Good Samaritanospital is a tertiary referral hospital with 564 acute care beds.esearch teams were first established in the 1997-1998 aca-emic year. Each research team consists of a faculty mentor, aenior resident, a mid-level resident, and an intern. When res-dents are assigned to the team, they maintain their team assign-
ents through the 5-year appointment. Each team takes chargef its project. The research teams are supported by research staffhat assist in project design, data reduction, statistical analysis,anuscript editing, and preparation of research presentations.
esearch teams help stimulate critical thinking, study design,
ectors in Surgery 0149-7944/06/$30.00doi:10.1016/j.cursur.2006.04.011
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nd evaluation of data. This assistance also gives the new resi-ents an opportunity to work on ongoing projects to under-tand the research mechanisms and how the multistep processorks. During orientation, the residents are provided a researchandbook describing the research curriculum, team rules, sup-ort staff, and expectations.A “Research Protocol” form (Fig. 1) is submitted before consid-
ration of any project and helps analyze the planned project, for-ulate the main idea, focus data collection, and assure that the
nalyzed data are meaningful and competitive. The main focus iso increase the amount of time spent up-front and time spent in theevelopment of study design. This structure was undertaken toevelop and aid in presenting the purpose of the study and assess-
ng the merit and feasibility of the study within the institution. Theesearch teams meet monthly; attendance is mandatory and is re-orded for all team members. The meeting times are determinedy the team leader. Each meeting is documented with minutesaken by the research staff. This structure was implemented tomprove individual research. The expectations for the teams arehat every resident will be assigned to a research team and requiredo be an active and contributing co-investigator on 1 team projecter year, an active co-investigator contributing to the developmentnd performance of the study, will participate in the writing of theanuscript, and must be able to defend the study. Any team mem-
er may present a project for approval at the committee, ie, Insti-utional Review Board (IRB), Institutional Animal Care and Useommittee (IACUC), or funding. This allowance has been veryelpful as not all rotations are performed at the parent institution,nd during outside rotations, committee presentations may be re-uired.
At the end of the first year, a case report should have beenrepared and submitted. The first-year resident will be an activearticipant on ongoing projects and will be developing an in-ividual project. It is the expectation that there will be a caseeport, a poster presentation, or slide presentation at a nationaleeting before completion of the resident’s training.At the end of the third year, each resident will complete an
ndividual project, not including case reports. The resident willlso be the principal investigator on 1 individual study outsidef the team. A completed manuscript suitable for publicationust be submitted to the surgery resident research specialist.his project will be presented in May of the third postgraduateear. The completed manuscript, compiled with the assistancef the research specialist, must also be ready to submit to aeer-reviewed journal at this time. Additional individualrojects are also strongly encouraged, especially if the residentas an interest in fellowship application or in further educa-ional opportunities.
Several different types of research projects are encouraged.ualitative studies use interviews and surveys of a particular
opulation regarding a specific issue. Case reports are encour-ged if they are reasonable, interesting, and publishable. Quan-itative studies include case-control, retrospective cohort, andross-sectional surveys. Prospective studies include observa-
ional or experimental studies. e
URRENT SURGERY • Volume 63/Number 6 • November/December 20
Some of the most common causes of unproductive or fruit-ess research have included lack of new or original ideas, con-used superficial research plans, lack of knowledge of previouslyublished relevant work, and lack of experience in essentialethodology. The general schema of the research projects in-
ludes formulation of initial idea, literature search, preparationnd writing of the research proposal, submission to the researchepartment with approval and funding if needed, collection ofata and patient enrollment and consent forms, the reductionnd analysis of the data, writing of the manuscript, referencehecks and peer review, and journal submission.
UPPORT
he E. Kenneth Hatton, MD, Institute of Research and Edu-ation was established at Good Samaritan Hospital in 1967ith biochemical research being first conducted in the hospital.riginal research programs were expanded in diverse areas, in-
luding cardiology, neonatology, oncology, urogynecology andascular surgery, under the direction of J. Robert Johnson, PhDnd John W. Vester, MD. The Institute was endowed in 1997ith a financial grant by Dr. E. Kenneth Hatton. This endow-ent provides financial stability and has provided funding foredical research, education and innovation.
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he Hatton Research Institute supports the work of 106 resi-ents in the TriHealth/Good Samaritan System and over 400esearch projects that are ongoing to improve the health care ofundreds of patients in the greater Cincinnati area. The re-earch staff includes a Director, 18 research nurses, 6 researchpecialists, research assistants, epidemiologists, IRB/Humanesearch Protection Administrator, IRB secretary, seniorhemist, life science laboratory veterinary technicians, and andministrative secretary.
The surgery research department has 1 full-time and 2 part-ime research specialists that are dedicated directly to the gen-ral surgery residents. Another research specialist works withhe vascular residents. Both full-time specialists have Master’segrees. The role of the research specialist is to provide consul-ation assistance to faculty and resident physicians in all aspectsf compiling and completing a research study, which includestudy design, protocol development and grant formation, writ-ng, data tabulation, statistical analysis, abstract writing, sub-
ission, creation of poster presentations, and education regard-ng research design and statistical analysis of the study. Inddition, the research specialist keeps the minutes and is ac-ountable for ensuring appropriate steps are being met in aimely manner to keep all projects moving forward, which in-ludes the coordination of the paperwork for the IRB, Institu-ional Animal Care and Use Committee (IACUC), and re-earch funding. The research specialist works with the medical
ducation program director and the surgical residency research
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FIGURE 1. Research protocol form.
28 CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
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irector to provide updates regarding all ongoing staff and res-dent projects.
Additional research staff includes the Director of Researchor General Surgery and the Surgical Research Director for the
atton Institute, who is currently a cardiovascular staff mem-er. The research director evaluates residents’ adherence to theround rules and attendance for the research meetings, as well ashe performance of the faculty mentors. The research directoreports directly to the program director (Fig. 2). The additionf a Resident Research Director has improved the amount ofroductivity in other programs.1 This position was establishedn the year 2000. The research director gives presentations andeports to the program director on residents’ progress and anyroblems with research. The use of a resident research director,he establishment of goals and expectations, the research curric-lum, dedicated time, faculty mentors, and the opportunity toresent at meetings, locally, regionally, and nationally haspurred research, and these have been listed as key elementsssential to successful resident research by Schultz.2 In emer-ency medicine academic productivity, only the program loca-ion and faculty size were associated with the number of publi-ations for a specific institution. The patient care load did noteem to influence the productivity.3 Residents in a largerrogram tended to participate more frequently in research,iting a need for a break from clinical work as a decidingactor. The benefits of research were also cited more com-only by residents in larger research programs as a stimulat-
ng factor to do research.4
acilities at Good Samaritan
he facilities include a biochemical laboratory, life sciences lab-ratory with 2 operating rooms, and a minimally invasive sur-ery training center with simulators, conference rooms, andffice space. The biochemical laboratory contains the integratedass spectrophotometer and the dynamic reactive cell induc-
Hatton Research Department Staff
Surgery Residents
Faculty Research Mentors
Surgery Research Director
Surgery Program Director
FIGURE 2. Research team.
ivity coupled plasma spectrophotometer. The meta-analysis m
URRENT SURGERY • Volume 63/Number 6 • November/December 20
apabilities of this equipment were expanded through the gen-rous funding of the Good Samaritan Hospital Foundation andhe Good Samaritans, the volunteer organization of Good Sa-aritan Hospital.The minimally invasive surgery training center provides op-
ortunities to practice innovative technologies that are replac-ng full open surgery using small incisions, minimizing patientlood loss and pain, and providing more rapid healing andeturn to work. Currently, the minimally invasive surgery train-ng center is equipped with 3 simulators: GI Mentor, Laparo-copic Trainer, and the LTS 2000 Laparoscopic Training Sim-lator. These simulators can be used by both the surgical andhe gynecologic residents. Additionally, the daVinci Surgicalystem is housed in the minimally invasive center for bothlinical and training purposes. This sophisticated series of ro-otic arms, coupled with a 3-demensional monitoring and im-ging, was also championed by the Good Samaritan Hospitaloundation and acquired through a generous support grantrom the Castellani Foundation, Claire Phillips, and Pam andob Sibcy. The conference rooms have also been staffed androvide a facility equipped with audio-visual technologies wiredirectly to the hospital operating rooms.Any projects using animals must meet with the approval of
he IACUC, and all activities are strictly conducted under theuspices of the IACUC. These activities are monitored by the.S. Department of Agriculture to assure conformity to the
uidelines. The animal facilities are fully staffed by a veterinaryechnician and an on-call veterinarian.
The IRB is designed to certify the integrity of every clinicalrial from beginning to endpoint, providing guidance and over-ight of each research component, including agreements, pro-ocols, and budgets. The Human Research Protection Programequires every clinical trial to gain administrative, departmen-al, and IRB approval before its undertaking. Approval verifieshat the research study achieves the necessary level of scientificerit and complies with all departmental, state, and federal
egulations. It also serves as a privacy board for TriHealth/Goodamaritan Hospital.
nformation Technology
he Hatton Institute provides the computer hardware and soft-are support for research, which includes the production and
upport for abstracts, manuscripts, and presentations. Onlineiterature reviews are conducted using MEDLINE and the Na-ional Library of Medicine’s database of references. Microsoftffice programs are used for data management (Excel and Ac-ess; Microsoft Corporation, Redmond, Washington), abstractnd manuscript preparation, and other word processingWord) and presentation design (PowerPoint). Additional soft-are programs in the Creative Suite package allow for photo
diting (Adobe Photoshop) and more advanced poster and pre-entation design (InDesign and Illustrator). Sample size deter-
ination is calculated using n-Query Analysis software. Statis-
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ical analysis of data is conducted using SPSS (SPSSorporation, Chicago, Illinois).The use of a unified medical record number beginning in
ugust 1993, where each patient is given a single medicalecord number and all patient activity is tracked through thisingle patient identifier, helps facilitate longitudinal data anal-sis and collection. Before the institution of this number, eachdmission and patient contact generated a separate patientdentifier that did not allow for longitudinal tracking of datand patient outcomes.
wards
esearch teams compete for awards. This award includes anxtra week’s vacation for the entire team. It is awarded on theasis of productivity for the past year and is announced at therand Rounds Research Competition held in May and at the
une resident graduation. In addition, there is a TriHealth Re-earch Competition for the TriHealth hospitals, J. Robertohnson TriHealth Research Competition, held annually, withash prizes awarded (First place $1000, Second place $500,hird place $250). The residents also compete at the annualincinnati Surgical Resident Competition in June where ab-
tracts may be submitted by all surgical residents in the Cincin-ati area, including the University of Cincinnati and Jewishospital, in addition to the Good Samaritan Hospital resi-
ents. Increasing the opportunities and the forums for presen-ation locally has been very stimulating for the research teamsnd has helped to facilitate a collegiality and a friendly compe-ition among the research teams.
ESULTS
ince the establishment of research teams in the 1997-1998cademic year, the number of ongoing projects has significantlyncreased, with over 400 projects open institutionally and 75pen surgical projects. There also been an increase in the num-er of publications and presentations. Although the increasedumbers have not yet achieved statistical significance, the qual-
ty of the projects and the resident involvement has increasedramatically. The spirit and interest of the residents in researchas also increased. Promotion may be denied if they have noteen actively participating with the research teams. Their re-earch team performance is considered annually in their perfor-ance appraisal and review before promotion. A sense of
riendly competitiveness that has developed between the teamsas been an unexpected benefit of having these research teams.This study was undertaken to review the effects of the devel-
pment of research teams to influence productivity, activity,resentations, and publications, in the area of research. Aethod of historical review was undertaken of the 8 years before
he establishment of research teams and the 8 years after theevelopment research teams to analyze the effect of researcheam development on publications and presentations by the
urgical resident staff. 3
30 CURRENT
Research team structure leads to the conducting of research,xposes learners to role models and mentors, and provides res-dent physicians with multiple opportunities to present theirork and be involved with a variety of projects throughout their
esidency training. During the 8 years before the research teams,9 presentations and 60 publications were accomplished by theeneral surgery residents. After the development of researcheams, the number of presentations is 92 and the number ofublications is 77. The quality of the research has shifted, with2.5% of publications published in peer-reviewed journals.reviously, peer-reviewed publications were 83%. The researcheams resulted in a 33% increase in presentations and a 13%ncrease in publications. The creation of more presentation op-ortunities has helped stimulate the junior residents.
ISCUSSION
he Guidelines of the Accreditation Council for Graduateedical Education (ACGME) advocate that each program pro-
ide an opportunity for residents to participate in research andther scholarly activities, and the resident must participate ac-ively in such scholarly activities. Participation in clinical andaboratory research is strongly encouraged.5 Research is consid-red a significant component for the growth and developmentf the practicing surgeon and can help develop scientific meth-dology and enhance surgical practice. Unfortunately, inade-uate scholarly activity on the part of the faculty and the resi-ents continues to be a frequent citation from the RRC inurgery and has been especially problematic in the communityetting. Upon completion of training, each resident must dem-nstrate acceptable scholarly activity, such as original research,omprehensive case reports, and a review of assigned clinicalnd research topics, and should have basic science literacy andnderstand the fundamental principles of clinical study designnd evaluation of research findings.5
Graduate residency training has accepted the mastery ofcore competencies.” These core competencies assist the physi-ians in training to acquire life-long professional buildinglocks, including patient care, medical knowledge, practice-ased learning and improvement, and interpersonal and com-unication skills. Application of evidence-based medicine and
ecision-making regarding patient care has become paramount.mproving the ability of the resident to review medical litera-ure critically is one side-benefit of active research participation.tructured resident research curriculum establishes expecta-ions, gives examples, develops timelines, and supports the de-elopment of hypotheses and project development. Obtainingpproval, funding, moving through the implementation phase,ata analysis and reduction, finalization, and leading to presen-ation and publication of manuscript are critical steps in theesearch process.
The authorship format is outlined and discussed at thenitiation of any study project by the research team to avoidny conflicts or confusion as the final stages are reached (Fig.
). Authorship requires substantial participation in all of the
SURGERY • Volume 63/Number 6 • November/December 2006
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ollowing conditions, including conception and design,nalysis and interpretation of the data, drafting the manu-cript, and revising it critically. The author order is a jointecision of the co-authors, and all must meet the definition
FIGURE 3. A
f authorship. d
URRENT SURGERY • Volume 63/Number 6 • November/December 20
There is an annual 6- to 8-week structured lecture series inuly and August that teaches critical thinking, evaluation of theiterature, statistics, and outlines guidelines for researchrojects, including the use of literature searches, hypothesis
ip guidelines.
evelopment, and tools for data collection. These lectures are
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eld weekly with the residents and the faculty. Presentationskills and communication issues are also covered annually at theorum. The Cincinnati Surgical Society also sponsors its ownesident-directed visiting lectures featuring ethics, research, andost recently, the American College of Surgeons on the chang-
ng paradigm of continuing education in surgery. Core compe-encies are also discussed and are a research tool for implemen-ation. Critical thinking is also reviewed as part of theincinnati Surgical Education project, which is held 3 timeser year in conjunction with the regional surgical programs.The most commonly listed obstacles to implementing resi-
ent research curriculum included resistance from the resi-ents, poor knowledge of research methods before beginningheir research, lack of resident motivation, resident misconcep-ions about research, failure of residents to meet deadlines, dis-greement about authorship, and poor resident attendance atesearch seminars. From a faculty mentor standpoint, obstaclesncluded a lack of faculty experience in supervising residents inesearch, resistance from the faculty, time and intensity de-ands of a research project, lack of faculty motivation for su-
ervising residents in research, faculty that had greater expecta-ions of a project than a resident could reasonably accomplish,nd faculty having little authority to persuade residents to per-orm research. From an institutional standpoint, lack of time inhe residency curriculum and scheduling difficulties were fre-uently encountered. Financial barriers, resistance from admin-stration in the hospital, and lack of clinical support staff werehe most commonly cited obstacles encountered in implement-ng resident research curriculum.6
Residents’ research may lead to better clinical care and criti-al appraisal skills, clinical reasoning, and life-long learningkills. Resident research training is an asset for those who arepplying for fellowships and jobs. Mentors must be extensivelynvolved and enthusiastic about resident research projects.7 Ex-osure to, and guidance from, mentors; training and basic re-
FIGURE
earch methods; protected time; and an environment support- m
32 CURRENT
ve of research have been identified as necessary to successfullyomplete research projects.7-10
The educational intervention with the research team and theesident director, mentorship, and the ability of the more senioresidents to serve as mentors to junior residents have been ex-remely helpful. The largest impediment to research activity inhis current system is actually achievement of funding. There isn endowment within the hospital and with the Good Samar-tans and the Bethesda Foundation that helps facilitate research,ut the ability to obtain funding remains one of the largestmpediments to research in this community program. Clearly,btaining funding is the biggest limitation to the success andompletion of research in this community hospital general sur-ery residency program. Varied extramural funding sources areeing explored and encouraged. Larger residencies have greateresearch output and had additional National Institutes ofealth and public funding.11
Senior residents can also serve on the research team as men-ors and collaborators. Collaborative research experience helpsoster teamwork and improves the relationship and attitudeithin the residency. Journal clubs are held regularly to im-rove resident literature reading skills and provide a venue toevelop skills of analytical review, teaching research methods,iostatistics, epidemiology, and the aptitude for research. Thebility to think, question, investigate, and apply criticallyhrough practice results in an exemplary physician who is al-ays learning how to improve treatment for future patients on
he basis of clinical experience from current patients and famil-arity of the medical literature.
ONCLUSION
ith the scientific practice of medicine, health care is deliveredy physicians who make observations, test the hypothesis, andxperiment with different treatment options. As medicine
ntinued)
oves forward, prevention of disease, care of acute and chronic
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llness, and resource utilization is carried out by both cliniciansnd researchers who have shared educational experiences.12 The
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esearch team model has allowed residents and students pursu- g
URRENT SURGERY • Volume 63/Number 6 • November/December 20
ng subspecialty training or an academic career to secure a fel-owship position after graduation from this residency pro-
ntinued)
ram.13 The research teams have been extremely successful with
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esident participation and are included in their annual evalua-ions. Giving the residents a set of expectations and the re-ources and facilitators to help them accomplish the goal, and tohen obtain funding and to have the time and support to criti-ally analyze and then present their data, has been well receivednd has worked well in this community general surgery resi-ency. The amount of interest in research and the productivityontinues to skyrocket. This residency program has a long his-ory of research resources, but the creation of research teams haselped focus and structure the efforts within the institution.ntegration of research within the curriculum has also beenritical to the success of this program.
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2. Schultz HJ. Research during internal medicine residencytraining: meeting the challenge of the residency reviewcommittee. Ann Int Med. 1996;124:340-342.
3. Henderson SO, Brestky P. Predictors of academic produc-tivity in emergency medicine. ACAD Emerg Med. 2003;10:1009-1011.
4. Stewart RD, Doyle J, Lollis S, Stone M. Surgical residentresearch in New England. Arch Surg. 2000;135:439-444.
FIGURE
5. Accreditation Council for Graduate Medical Education
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Directory. Program Requirements for General SurgeryResidency Training. Directory, American MedicalAssociation, 2005-2006. Chicago, IL, 2005.
6. Hebert RS, Levine RB, Smith CG, Wright SM. A system-atic review of resident research curricula. Acad Med. 2003;78:61-68.
7. Lambert MT, Garver DL. Mentoring psychiatric trainees’first paper for publication. Acad Psychiatry. 1998;22:47-55.
8. Bland CJ, Schmitz CC. Characteristics of the successfulresearcher and implications for faculty development.J Med Educ. 1986;61:22-31.
9. Bland CJ, Ruffin MT. Characteristics of a productive re-search environment: literature review. Acad Med. 1992;67:385-397.
0. Temte JL, Hunter PH, Beasley JW. Factors associatedwith research interest and activity during family practiceresidency. Fam Med. 1994;26:93-97.
1. Itagaki MW, Pile-Spellman J. Factors associated with ac-ademic radiology research productivity. Radiology. 2005;237:774-780.
2. Association of Professors of Medicine. Residents as re-searchers: expectations, requirements, and productivity.Am J Med. 2003;115:510-515.
3. Lampman RM, Wolk W, Fowler J, et al. Resident researchtraining conducted in a community hospital general sur-
