Introduction
General surgery is unique among graduate medical education programs in that up to 36% of residents interrupt their residency training to pursue full-time research.1 Additionally, residents may use this gap in clinical training to pursue advanced degrees in basic science, public health, or business administration; participate in advocacy work; or pursue select fellowships.2-4 Allowing residents to determine what activities best advance their future goals is also in better alignment with the preferences of younger generation surgeons.5 Given the broader scope of scholarly activities residents may perform during this period, the term “dedicated value-added year” may be more accurate than the term “dedicated research year.” The importance of pursuing scholarly activities during residency training has also been codified as a core requirement by the Accreditation Council for Graduate Medical Education (ACGME).6
Despite the longstanding practice of residents interrupting their surgical training to pursue scholarly activities, the benefits and impacts of disrupting the flow of clinical training remain a topic of debate.
The Pro Arguments
Dedicated time to pursue research or other professional advancement opportunities benefits the residents, the faculty who serve as their mentors, and the residency program.
Given the frequent focus on clinical productivity, meeting the ACGME core requirement for scholarly activites6 may be difficult. By incorporating dedicated research time into the residency structure, programs can more easily meet this requirement.1,7 With ACGME duty hour limitations6, a dedicated year of research provides an opportunity for residents to significantly increase scholarly output8,9 while also serving as a bullpen of additional clinical work force.
With nearly 75% of residents pursuing fellowship training, the competition for these positions has become intense.10 Publications, presentations, and formal research experience are heavily favored during the selection process.11-14 Those who obtain an additional advanced degree during residency have significantly more research output and sustained scholarly productively beyond residency.15-17
Recently, there has been a notable decline in physician-scientists.18 Residents who participate in research are more likely to receive faculty appointments and obtain federal grant funding.19 One method of re-establishing this pipeline is by facilitating research during residency training.20
Navigating a resident from the clinical to the research environment and ensuring their success requires intentional execution. Zuo and others have nicely outlined key considerations, decisions, and pearls for surgical residents and program directors to consider when establishing a dedicated research experience.21,22
In addition to research and obtaining advanced degrees, fellowships in surgical critical care and burn surgery may be pursued during residency training. While the American Board of Surgery does not grant official board certification until general surgery certification is achieved, this option allows trainees to graduate from residency with added qualifications.
Burnout is a nearly ubiquitous, global problem among surgical residents.23-25 One mitigation strategy is the use of a research or value-added year.24 Felton and colleagues found the biggest improvement in resident wellness came in the research year compared with the previous year.26 Other benefits for residents include the opportunity to make additional money moonlighting and the opportunity to expand their families, without the stress of clinical responsibilities.
There are several other likely benefits that are not well represented in the literature. Success in research provides residents an opportunity to improve their public speaking and presentations skills, as well as the chance to network with others outside their home institution. Resident success also enhances the reputation of the residency program.
While the above commentary articulates the benefits of a dedicated research or value-added year, there are also significant downsides.
The Con Arguments
The ACGME requires that surgical residents be trained with an organized curriculum and allowed progressively greater levels of responsibility.6 Interruption of the normal training sequence has shown to be detrimental to surgical maturation.25-30
Surgical residents who return to clinical training perceive that their skills have decayed during their research time.27,28 The greatest skill reduction occurred for more complex procedures, such as ventral hernia repair and bowel anatamosis.27 Residents also recognized a decline in their level of confidence,26 clinical judgment,28 and leadership skills.29 While time away from clinical duties may improve burnout,25 returning at a more senior level of training with less confidence, clinical judgment, and skill may lead to increased levels of burnout.24,25
Not unexpectedly, the faculty also perceive a significant decay of resident skills, clinical judgment, and confidence upon reentry into the clinical environment.26,29 Residents require more instruction about technical skills and procedural steps by the faculty.27 While research output is heavily valued in the fellowship selection process,11-13 faculty letters of recommendation describing operative skills and clinical judgment are of equal, if not greater importance.11-13
Another criterion for fellowship selection is performance on the in-service training exam.11-13 While dedicated time away from clinical rotations may increase time for independent study, it has been demonstrated that scores on the in-service training exam plateaued for residents during the research year, and they continued to improve year-over-year for those who continued clinical training.30 In particular, residents who spent 2 or more years away from clinical responsibilities saw performance stagnation in their written exams and oral exam performance.30 For residents who are struggling, time away from the clinical environment may significantly worsen their performance. In this situation, participation in simulation-based activities may be a mitigation strategy.
Non-compliance with ACGME duty hours6 may be avoided by having an additional pool of residents to draw from. However, with mean length of dedicated research time being 1.7 years, the cost of employing an additional cohort of research residents may be excessive.1 In 2009, Robertson and colleagues found that it cost $41.5 million/year to pay for 634 trainees pursuing research.1 Much of this cost was incurred by the department.
With respect to research productivity, dedicated research time indeed improves scholarly output by the residency program.8,9 Unfortunately, this is highly variable among individual residents and faculty mentors, with only a minority of trainees publishing their work in peer-reviewed journals.22 Given the time required to be efficient in research methods, a single year may be insufficient to achieve significant productivity.
Research time during residency may also have a negative impact on the distribution of the surgical workforce. There is a significant association of residents who have done research with a 15% increase in fellowship application and a 15% decrease in entry into private surgical practice for each year of dedicated research time during residency.1 Residents who are mandated to do a research year are delayed in obtaining the financial benefits of entering the surgical workforce. This additional time living on a resident’s salary may significantly stress the resident and their family.
Conclusion
There are both pros and cons for residents, residency programs, and the future of surgery associated with dedicated research time. These factors must be considered when contemplating entry into or the establishment of such programs.
