Research during residency training: good for all?

Abstract

The report by Cull et al1.Cull W.L. Yudkowsky B.K. Schonfeld D.J. Berkowitz C.D. Pan R.J. Research exposure during pediatric residency: influence on career expectation.J Pediatr. 2003; 143: 564-569Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar suggests that current shortages in the numbers of pediatric researchers may be partly linked to a lack of exposure to research during general pediatric residency training. It is also suggested that participation in a research experience during residency training might increase the number of residents who go on to subspecialty training. This information, obtained from periodic surveys of residents completing their training, is interesting and informative, but we are left with a number of unanswered questions. Is there truly a causal link between participation in research activities during general pediatric residency and the likelihood with which a person will go on to further training at the subspecialty level? Which is the chicken and which is the egg in this regard? What are the major factors that influence the choice of a subspecialty career? Is there a broader goal to be achieved by involvement in scholarly activities during residency training? Last, even if it were desirable to increase the exposure to research during residency training, is it possible to do so, given the many competing educational requirements imposed on programs these days?The factors influencing the numbers of persons who enter the subspecialty workforce are complex and the inclusion of more research experience in general pediatric residency may not influence these numbers in any major way. The subspecialty workforce seems to be driven more by market influences reflective of supply and demand than by manipulation in the design of general pediatric residency training. When demand exceeds supply, the word “gets out” and the market responds. Witness the trend that has occurred in recent years. Throughout most of the 1990s, the emphasis in healthcare in the United States was on primary care. The proportion of residents entering subspecialty training fell markedly during this period. In 1998, just 18% of those completing general pediatric training entered subspecialty fellowships, representing a total of 684 persons. It then became apparent that we were training an insufficient number of subspecialists. By 2002, the number of first-year fellows increased to 1000, presumably in response to demonstrated shortages. An informed marketplace seems to adjust itself quickly. We also do not know whether greater exposure to research during the core three years of general pediatric residency training strongly influences the probability that a person will seek additional research training after completion of the residency. The correlations described by Cull et al could simply reflect the fact that those who are highly likely to take further training are those persons who are also likely to seek out research experiences during residency. Also, a single elective or mandatory research experience seems unlikely to completely realign one's career trajectory so late in overall training. The seed that leads to the development of a scholarly career is cultivated in soil that begins long before the start of residency. Stiehm reminded us of this fact some 15 years ago in an editorial.2.Stiehm E.R. Some of my best clinical pediatricians are researchers.Am J Dis Child. 1988; 142: 1283Google Scholar He noted that research training for medical trainees is like music lessons for a 5-year-old child. The experience is good for the child, even though few appreciate that fact initially and even fewer will become rather good at music. By analogy to music lessons, few medical trainees will ultimately become highly-accomplished researchers, but most can gain something from a research experience. Although it is possible to cultivate seeds of interest as late as residency training, it is far better to do this much earlier, perhaps while in high school or college. Many medical schools encourage research training, but few mandate it. So what are some of the real values of exposure to research during residency? Winter summarized the experiences at the Children's Memorial Hospital, where a research requirement during general residency has been in place since 1971.3.Winter R.J. Research during residency.Am J Dis Child. 1989; 143: 521PubMed Google Scholar All residents at this Chicago institution must complete a research project to fulfill the requirements for residency training. During the first 15 years of this requirement, more than 150 research projects had been performed, completed, and presented to faculty at the end of the third year of residency training. Nearly one third of the projects were published in the medical literature, although this was not a goal of the requirement. The intent of the program has not been to make researchers out of those in general pediatric residency training nor to foster an interest in subsequent subspecialty training. The goal is to begin to stimulate a lifelong interest in addressing questions that we all face on a daily basis in the practice of medicine, be it in the subspecialty arena or in primary care. Jay Lowder, a third-year general pediatric resident in the Children's Memorial Hospital training program, as part of his research project in 1995, surveyed 173 graduates of the program to assess the long-term benefits of the residency research requirement.4.Sharon Unti, Residency Program Director, Department of Pediatrics, Northwestern University, The Feinberg School of Medicine and Children's Memorial Hospital, Chicago, Illinois (personal communication).Google Scholar The majority of respondents found the experience of value and would opt to do it again even if it were optional. They found significant value in the application of knowledge gained from the experience to their subsequent careers. Many of those finishing training at Children's Memorial have continued to participate in some form of research, including research performed in the setting of a general pediatric practice. The Pediatric Practice Research Group and the American Academy of Pediatrics' Pediatric Research in Office Settings (PROS) network are examples of how general practitioners can actively contribute to our understanding of disease processes.5.Christoffel K.K. Binns H.J. Stockman III, J.A. McGuire J. Poncher J. Unti S. the Pediatric Practice Research Group et al.Practice-based research: opportunities and obstacles.Pediatrics. 1988; 82: 399-406PubMed Google Scholar, 6.Haggerty R.J. Green M. History of academic, general, and ambulatory pediatrics.Pediatr Res. 2003; 53: 188-197Crossref PubMed Scopus (11) Google Scholar Participation in scholarly activity during residency training appears to foster the development of intellectual curiosity and helps one to read the literature with a critical eye and with a solid understanding of study design, research methodology, and statistical analysis.The rub with participation in research activity is that it must be balanced within an increasingly full residency training curriculum. The recent introduction of stricter work hour regulations further adds to the constraints. For example, after being on-call the night before, a trainee may not go to the laboratory or engage in a clinical research project any differently than were he or she to be caring for patients. The trainee will find, however, that the time spent in research and other scholarly activities will assist in the preparation for Board certification. The American Board of Pediatrics, while neither encouraging nor discouraging involvement in research during general pediatric residency training as part of its eligibility requirements to take the certifying examination in general pediatrics, does require a working knowledge of research study design and methodology, as well as an understanding of statistics related to the biomedical arena and the principles of evidence-based medicine. A candidate taking the certifying examination will likely see questions related to these subjects. Active involvement in a research project during residency training will, if appropriately structured, foster the acquisition of such knowledge.No one can deny that properly mentored participation in research, over and above clinical training, has merit during general pediatric residency training. Research experiences may or may not foster the development of a greater cadre of physician-scientists, but, like music lessons, they are of value for virtually everyone. The report by Cull et al1.Cull W.L. Yudkowsky B.K. Schonfeld D.J. Berkowitz C.D. Pan R.J. Research exposure during pediatric residency: influence on career expectation.J Pediatr. 2003; 143: 564-569Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar suggests that current shortages in the numbers of pediatric researchers may be partly linked to a lack of exposure to research during general pediatric residency training. It is also suggested that participation in a research experience during residency training might increase the number of residents who go on to subspecialty training. This information, obtained from periodic surveys of residents completing their training, is interesting and informative, but we are left with a number of unanswered questions. Is there truly a causal link between participation in research activities during general pediatric residency and the likelihood with which a person will go on to further training at the subspecialty level? Which is the chicken and which is the egg in this regard? What are the major factors that influence the choice of a subspecialty career? Is there a broader goal to be achieved by involvement in scholarly activities during residency training? Last, even if it were desirable to increase the exposure to research during residency training, is it possible to do so, given the many competing educational requirements imposed on programs these days? The factors influencing the numbers of persons who enter the subspecialty workforce are complex and the inclusion of more research experience in general pediatric residency may not influence these numbers in any major way. The subspecialty workforce seems to be driven more by market influences reflective of supply and demand than by manipulation in the design of general pediatric residency training. When demand exceeds supply, the word “gets out” and the market responds. Witness the trend that has occurred in recent years. Throughout most of the 1990s, the emphasis in healthcare in the United States was on primary care. The proportion of residents entering subspecialty training fell markedly during this period. In 1998, just 18% of those completing general pediatric training entered subspecialty fellowships, representing a total of 684 persons. It then became apparent that we were training an insufficient number of subspecialists. By 2002, the number of first-year fellows increased to 1000, presumably in response to demonstrated shortages. An informed marketplace seems to adjust itself quickly. We also do not know whether greater exposure to research during the core three years of general pediatric residency training strongly influences the probability that a person will seek additional research training after completion of the residency. The correlations described by Cull et al could simply reflect the fact that those who are highly likely to take further training are those persons who are also likely to seek out research experiences during residency. Also, a single elective or mandatory research experience seems unlikely to completely realign one's career trajectory so late in overall training. The seed that leads to the development of a scholarly career is cultivated in soil that begins long before the start of residency. Stiehm reminded us of this fact some 15 years ago in an editorial.2.Stiehm E.R. Some of my best clinical pediatricians are researchers.Am J Dis Child. 1988; 142: 1283Google Scholar He noted that research training for medical trainees is like music lessons for a 5-year-old child. The experience is good for the child, even though few appreciate that fact initially and even fewer will become rather good at music. By analogy to music lessons, few medical trainees will ultimately become highly-accomplished researchers, but most can gain something from a research experience. Although it is possible to cultivate seeds of interest as late as residency training, it is far better to do this much earlier, perhaps while in high school or college. Many medical schools encourage research training, but few mandate it. So what are some of the real values of exposure to research during residency? Winter summarized the experiences at the Children's Memorial Hospital, where a research requirement during general residency has been in place since 1971.3.Winter R.J. Research during residency.Am J Dis Child. 1989; 143: 521PubMed Google Scholar All residents at this Chicago institution must complete a research project to fulfill the requirements for residency training. During the first 15 years of this requirement, more than 150 research projects had been performed, completed, and presented to faculty at the end of the third year of residency training. Nearly one third of the projects were published in the medical literature, although this was not a goal of the requirement. The intent of the program has not been to make researchers out of those in general pediatric residency training nor to foster an interest in subsequent subspecialty training. The goal is to begin to stimulate a lifelong interest in addressing questions that we all face on a daily basis in the practice of medicine, be it in the subspecialty arena or in primary care. Jay Lowder, a third-year general pediatric resident in the Children's Memorial Hospital training program, as part of his research project in 1995, surveyed 173 graduates of the program to assess the long-term benefits of the residency research requirement.4.Sharon Unti, Residency Program Director, Department of Pediatrics, Northwestern University, The Feinberg School of Medicine and Children's Memorial Hospital, Chicago, Illinois (personal communication).Google Scholar The majority of respondents found the experience of value and would opt to do it again even if it were optional. They found significant value in the application of knowledge gained from the experience to their subsequent careers. Many of those finishing training at Children's Memorial have continued to participate in some form of research, including research performed in the setting of a general pediatric practice. The Pediatric Practice Research Group and the American Academy of Pediatrics' Pediatric Research in Office Settings (PROS) network are examples of how general practitioners can actively contribute to our understanding of disease processes.5.Christoffel K.K. Binns H.J. Stockman III, J.A. McGuire J. Poncher J. Unti S. the Pediatric Practice Research Group et al.Practice-based research: opportunities and obstacles.Pediatrics. 1988; 82: 399-406PubMed Google Scholar, 6.Haggerty R.J. Green M. History of academic, general, and ambulatory pediatrics.Pediatr Res. 2003; 53: 188-197Crossref PubMed Scopus (11) Google Scholar Participation in scholarly activity during residency training appears to foster the development of intellectual curiosity and helps one to read the literature with a critical eye and with a solid understanding of study design, research methodology, and statistical analysis. The rub with participation in research activity is that it must be balanced within an increasingly full residency training curriculum. The recent introduction of stricter work hour regulations further adds to the constraints. For example, after being on-call the night before, a trainee may not go to the laboratory or engage in a clinical research project any differently than were he or she to be caring for patients. The trainee will find, however, that the time spent in research and other scholarly activities will assist in the preparation for Board certification. The American Board of Pediatrics, while neither encouraging nor discouraging involvement in research during general pediatric residency training as part of its eligibility requirements to take the certifying examination in general pediatrics, does require a working knowledge of research study design and methodology, as well as an understanding of statistics related to the biomedical arena and the principles of evidence-based medicine. A candidate taking the certifying examination will likely see questions related to these subjects. Active involvement in a research project during residency training will, if appropriately structured, foster the acquisition of such knowledge. No one can deny that properly mentored participation in research, over and above clinical training, has merit during general pediatric residency training. Research experiences may or may not foster the development of a greater cadre of physician-scientists, but, like music lessons, they are of value for virtually everyone.