Scholarly Activity – A Program Director’s Observations
"Somewhere, something incredible is waiting to be known." - Carl Sagan
Graduate medical education involves a formal period of training after medical school in order to prepare the physician for independent medical practice. With (at last count) 126 different specialties and subspecialties and their unique expertise in the delivery of medical care, developing comparable training standards is a daunting task. The mission of the Accreditation Council for Graduate Medical Education (ACGME) to “improve health care by assessing and advancing the quality of resident physicians’ education through accreditation” of these programs is both ambitious and necessary for the general public to recognize its endorsement as representative of excellence. Fortunately, enough commonalities exist within each training program that permit uniform requirements to become established. The Common Program Requirements (CPR) are published by the ACGME in order to standardize many aspects of the education process (1). One of the fundamental elements of resident education is exposure to and participation in evidence-based medicine. Unlike many of the other CPR, this activity requires a high degree of sustained effort in order to produce ongoing results. As a program director, it is useful to re-examine this research requirement and review its relation to medical education and the health care field. The following observations are derived from my experience in Internal Medicine, nevertheless these basic principles can also apply to other specialty training programs.
Scientific inquiry and research is an integral feature of the CPR. However, the wording of the requirement within this document is sufficiently vague, e.g. “the curriculum must advance residents’ knowledge of the basic principles of research…” or “Residents should participate in scholarly activity”, to allow an individual program some freedom to interpret and to determine whether it fulfills this obligation. In certain specialties, their program-specific requirements clarify these statements by providing quantifiable criteria that define acceptable scholarly activity. In general, there is enough ambiguity in the terminology that allows a number of different interpretations, with the result that this requirement’s perceived intent and result are markedly dissimilar among specialties. In any case, the fundamental obligation to produce an adequate quantity and quality of research is often a source of angst for most programs.
With more barriers to achieving the goal of adequate research activity and the threat of a “publish or perish” mentality applying to each training program, residency program directors now face a greater challenge to comply with this mandate. Limits to resident duty hours including the recent Institute of Medicine recommendations, reduced hospital reimbursement and revenue as well as the threat of lower GME funding, more stringent outcomes requirements in other ACGME initiatives such as specialty board passing rate all compete and consume from the same pool of financial and personnel resource within each institution. This often leads to conflicts in prioritizing asset allocation among hospital administrators, clinical educators, and physician faculty.
In spite of this, most training programs in Internal Medicine are able to provide evidence of resident research and scholarly activity. The great majority of these are topic reviews with presentation and case reports. This achievement belies the effort required to produce such statistics. Indeed formidable deterrents threaten to undermine the continuation of such accomplishments. According to one survey, the top perceived barriers identified by program directors are due to lack of faculty time and lack of funding (2). For the clinician educator affiliated with a community hospital-based training program, “protected time” for research is often unavailable. Unless they are recipients of grants or other external funding sources, these faculty must make a choice between income-generating activity and scholarly investigation. Interestingly, in another survey of department chairs and senior research administrators in U.S. medical schools, 93% of respondents stated that pressure to see patients is also a moderate-to-large problem for clinical research (3).
There is no argument that quality clinical and basic science research is vital to maintaining our role as leaders in health care. Exposure to these resources can stimulate interest in evidence-based medicine and perpetuate an attitude of lifelong learning. Internal medicine resident alumni view these experiences as worthwhile, especially in improving the ability to review the medical literature critically (4). A significant percentage of these alumni also reported that these research activities influenced their career choices. Not surprisingly, a majority of graduates also believe that completion of a scholarly project should be a prerequisite for successful completion of a residency program (5).
The future impact of mandating scholarly activity is uncertain. In this economy, the ongoing possibility of reduced reimbursement for medical care and graduate medical education imposes additional pressure on institutions to meet the fiscal bottom line. Because residency training programs and health care facilities are inexorably linked, realignment of corporate strategic goals will have a fundamental impact on all facets of operation, including education. Again, this may force a re-prioritizing of certain projects to a subordinate level, especially if the activities do not produce income. Curiosity about the scientific discovery process should ideally be cultivated in all students of medicine. Training institutions and program directors are in a unique position to provide this experience. Future innovative approaches toward this goal to minimize cost will likely increase. In the meantime, alternative training tracks with a focus on research while maintaining Board eligibility have already been established. For example, the American Board of Internal Medicine has created a Research Pathway for trainees planning academic careers as investigators in basic and clinical science, but at the cost of a longer period of training (6). It also has additional pathways to incorporate subspecialty training in this Pathway as well. The desirability of spending an additional 2 years in this manner remains to be determined, however.
Scholarly activity is rewarding in its own right. However, it is an obligation that must be embraced by many members of the teaching faculty. Overcoming the additional sources of frustration from the practice of modern medicine makes each achievement that much more worthy. Remarkably, it is attainable by almost all programs regardless of academic status, confirming that scholarly activity is not just for scholars.
Kenneth Ong, MD
Program Director, Internal Medicine Residency
The Brooklyn Hospital Center
121 DeKalb Ave
Brooklyn, NY 11201
- Common program requirements. Available at: http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf
- Levine RB, Hebert RS, Wright SM. Resident research and scholarly activity in internal medicine residency training programs. J Gen Intern Med. 2005;20:155-9.
- Campbell EG, Weissman JS, Moy E, Blumenthal D. Status of clinical research in academic health centers: view from the research leadership. JAMA. 2001;286:800-6.
- Hayward RA, Taweel F. Data and the internal medicine houseofficer: alumni’s views of the educational value of a residency program’s research requirement. J Gen Intern Med. 1993;8:140-2.
- Rivera JA, Levine RB, Wright SM. Completing a scholarly project during residency training. J Gen Intern Med. 2005;20:366-9.
- American Board of Internal Medicine. Policies and procedures for certification, July 2008.