Keywords
resident - research - orthopedics
Introduction
Involvement in research has become a fundamental aspect during residency training
of orthopedic surgeons, as it has shown to develop critical-thinking skills that are
necessary for the clinical practice.[1]
[2]
[3]
[4] The Accreditation Council for Graduate Medical Education (ACGME) and the Royal College
of Physicians and Surgeons of Canada (CanMEDS) advocate for training programs to encourage
research participation.[5]
[6] Accordingly, interest has increased on the variables that make an impact on the
rate of publication by orthopedic residents.[2]
[3]
[7] Protected time for research appears to play a significant role in the rate of publication,
which is significantly different among residents from different programs.[5]
[7] The same interest in resident publications has been reported in Latin American countries.[8]
[9] However, a recent study[10] showed that only 1% of the orthopedic literature published between 1988 and 2013
originated from this region. Different questions arise based on this evidence: are
orthopedic residents from Latin America actively involved in research? How many articles
do they publish? Is there a disparity with North American countries? To our knowledge,
there is insufficient published data to answer these questions. The primary objective
of the present study was to determine the average number of indexed articles published
per orthopedic resident in Chile, and, secondarily, to establish if protected research
time for residents was associated with a higher number of publications.
Methods
A transverse descriptive study was developed. A list of all orthopedic residency programs
in Chile was obtained from the Chilean Society of Orthopedic Surgery (SCHOT). Every
institution's curriculum was reviewed, and any mention of protected time for research
was recorded. The full names of the residents who graduated between 2012 and 2016
was recorded, and, if a program did not have graduates in this period, it was excluded
from the analysis. Lastly, each program was contacted directly to confirm the information.
Search criteria: articles indexed on PubMed authored or co-authored by the orthopedic
residents with a publication date between 6 months after the beginning of their training
and 12 months postgraduation were included. Letters to the editor, articles not related
to orthopedic surgery, and those with an institutional affiliation other than their
training program were excluded. The first and last names of each resident were searched
on the electronic database. To prevent data from being tainted due to the possibility
of multiple researchers having the same names, the names and institutional affiliations
of the co-authors were checked as well.
The number of articles published by each resident was recorded to determine the publication
rate per resident and per program. A subsequent analysis was performed according to
each journals' impact factor (at the time of the review) and the level of evidence
of each article. Clinical trials were classified according to the Oxford Centre for
Evidence-Based Medicine Levels of Evidence.[11]
The electronic search was performed in August 2017 by two independent researchers.
All data was stored using Google Sheet (Alphabet), and data analysis was performed
using the Stata (StataCorp, LLC, College Station, TX, US) software, version 12.0.
Source of Funding
No funding from any source was received for this investigation.
Results
Twelve orthopedic surgery residency programs in Chile were identified, all with a
training duration of three years. Two were excluded from the analysis because no residents
had graduated from them at the time of analysis. In total, 272 residents were included,
with an average of 27.2 ± 22.9 (range: 7 to 85) residents per program. The inclusion
criteria were fulfilled by 72 studies (2 articles were excluded because they were
letters to the editor). The studies were authored by 29 (10.6%) of the 272 residents.
The publication rate was 0.26 ± 1.13 (range: 0 to 13) articles per resident during
training. Overall, 2 programs stood out, with an average of more than 1 article published
per resident (2.6 and 1.3 articles). Half of the programs had at least one resident
who had published an article during their residency ([Fig. 1]). Among the published articles, there were 42 clinical trials, 12 experimental studies,
and 18 reports, including surgical technique guides and the validation of clinical
outcome measures and disease classification systems. The level of evidence for each
clinical trial is shown in [Table 1], with the majority corresponding to level-IV or -V studies (78.5%). The journals
in which Chilean residents published the most and their corresponding impact factors
are summarized in [Table 2]. None of the ten training programs mentioned protected time for research; therefore,
no analysis could be made to establish if the existence of protected time for research
correlated with the number of publications.
Fig. 1 Average number of articles published by residents per program. The orange line indicates
the average publication rate of all residents.
Table 1
|
Level of evidence
|
Number of publications
|
|
I
|
0
|
|
II
|
4
|
|
III
|
5
|
|
IV
|
29
|
|
V
|
4
|
Table 2
|
Journal
|
Scimago Journal & Country Rank
|
Number of publications
|
|
Spine
|
1.736
|
10
|
|
European Spine Journal
|
1.535
|
8
|
|
Revista Española de Cirugía Ortopédica
|
0.28
|
8
|
|
Knee
|
1.244
|
7
|
|
International Orthopaedics
|
1.502
|
5
|
|
Arthroscopy
|
1.459
|
5
|
|
Foot and Ankle International
|
1.626
|
4
|
|
Injury
|
0.99
|
4
|
|
Revista Médica de Chile
|
0.26
|
4
|
|
American Journal of Sports Medicine
|
3.949
|
3
|
Discussion
There is a rising interest in research in Latin American countries,[8]
[9] but the number of indexed publications on orthopedics is still lacking from this
region when compared with others.[10] Encouraging residents to perform scientific research could be of great interest
to these countries, as it has been shown that residents who publish during their training
programs tend to continue working on research projects during their careers.[4]
[6]
[12]
[13] However, we do not know what proportion of residents actually do manage to successfully
publish an article. To our understanding, there are no reports describing the involvement
in research by Latin American orthopedic surgery residents.
The results of the present study showed that a Chilean orthopedic surgery resident
publishes on average 0.26 ± 1.13 articles in a 3-year period. A recent study[7] from the United States, which included 1,690 residents from 125 orthopedics programs,
showed a publishing rate of 1.2 ± 2.4 articles per resident in a 5-year period. Among
Canadian orthopedic residents, the publication rate during 1 year of training was
of 0.42 ± 0.9, which is also higher than the Chilean rate.[5] Multiple factors could explain this difference, such as the total duration of the
training (5 years versus 3 years), language, a dedicated research program,[14]
[15] faculty mentorship commitment,[4]
[14]
[16]
[17] access to a research medical editor, the provision of grants,[14] tgw possibility of primary authorship,[18] the possibility of an elective research year,[19] work hour restrictions,[5]
[20]
[21] and protected time for research.[5]
[7]
[14]
Some of these factors could be of interest to apply in local residency programs, as
restructuring them has resulted in a significant increase in grants and publications
in other regions such as North America.[14]
[15]
[22] Robbins et al.,[14] for example, showed an increase in the publication rate from 1.3 to 9.3 articles
per resident during orthopedic training after adjustments in the research curriculum.
Regarding protected time for research, the study by Williams et al.[7] showed that American orthopedic surgery residents who had designated time for research
published significantly more than those who had not. The same has been demonstrated
by Chan et al.[5] regarding Canadian orthopedic residents, with a mean amount of protected time of
5 ± 7.3 months. In their study,[5] they also showed that 41% of the surveyed residents answered that time was the biggest
obstacle for research. In the present analysis, none of the Chilean programs reported
protected time for research.
It is important to remark that there is a wide range of articles published among Chilean
residents (0 to 13 publications). When comparing the different residency programs,
we identified that two of them concentrated those residents who published the most.
These were the only ones with a publication rate of more than one article per resident,
reaching the North American average.[7] In the other eight programs, the publication rate was near zero. The possible explanations
for these differences include the aforementioned reported variables, but we also believe
that the research background of the student is also a factor that could impact publication
rates, as some programs might have a higher proportion of residents that already have
a baseline experience and interest in research.
The analysis of the articles published by the Chilean residents showed that many were
published in high-impact orthopedic journals ([Table 1]). However, this does not necessarily guarantee the quality of the article.[15] Furthermore, most of the clinical trials included in the present study (78.5%) had
a level of evidence of IV or V ([Table 2]).
The present study has limitations that may have led to selection bias. First, the
database search was conducted exclusively on PubMed; therefore, publications that
were not indexed on PubMed were excluded. This database was used because it is the
leading search engine for scientific evidence,[23] it includes all major journals,[24] and is consistent with the methods of the current literature.[5]
[7] Second, the time limit set for the inclusion criteria for published articles (6
months after beginning the residency up to 12 months postgraduation) was arbitrarily
defined in a way to ensure only the inclusion of articles that were developed by residents
during their training. These criteria might have caused the publication rate to be
under- or overrated. As with several descriptive studies, the generalization of our
results is also limited, because some comparisons were made using the published literature.
For a more accurate analysis, future investigations could focus on conducting transverse
comparative studies between Latin and North American orthopedic residents.
Based on our knowledge, the present is the first study to report the current state
of involvement in research and the number of publications by orthopedic residents
in a Latin American country. Upcoming studies in Chile should focus on identifying
the differences between orthopedic residency programs, to recognize the key variables
that lead a group of students from the same country to stand out among their peers.
It would also be valuable to assess the resident's opinion about factors that influence
their success in developing and publishing research.
Conclusions
The present study determined that the average number of publications indexed on PubMed
per orthopedic resident in Chile is of 0.26 ± 1.13 articles, which is lower than that
of their North American counterparts. Only 10% of them publish an article during their
residency. None of the Chilean programs specified protected time for research; therefore,
no correlation between this variable and the number of articles published by residents
could be established.
