Creating an Academic Culture during Residency Training
Article Outline
- Research During Residency
- Special Research Tracks
- Financial Support for Research and Academic Careers
- Mentors and Advisors
- References
- Copyright
Although the core educational mission of residency training is the acquisition of pediatric knowledge and its application to the care of the patient, knowledge of research and the development of scholarly pursuits are additional important expectations. The Boston Combined Residency Program was established in 1996 as a fusion of existing pediatric residencies affiliated with Harvard Medical School and Boston University School of Medicine. It has as a core mission the training of residents as excellent pediatricians but also emphasizes preparation for academic leadership in the general and subspecialty disciplines.1, 2 We will review the literature and outline experiences that we believe enhance an academic culture in pediatric residency.
Research During Residency
The opportunity to pursue research during residency has been described in many different specialties of medicine. Although the nature of research rotations, curriculum, year of exposure, and whether participation is elective or mandatory vary widely, incentives and impediments are similar. Successful outcomes are enhanced if (a) research projects and the rotation are held to be important by the departmental chair and program director; (b) the leaders of the rotation and project mentors are actively involved; (c) the goals of the rotation are clear to residents and faculty; (d) a defined, dedicated, mandatory block of time is in the curriculum; and (e) funding for projects and travel, biostatistical and study design expertise, and informatics resources are available.2, 3, 4, 5, 6 Advanced degrees, prior research experience, and current research interest are associated with individual resident success.6
Five years ago, we instituted a required 3-month research block of protected time in the senior year. Four groups of 9 senior residents participate in the block rotation each year. Led by 2 senior faculty researchers, the rotation includes a weekly 3-hour seminar with a focused curriculum covering topics such as research on human subjects, clinical trial design, developing an academic career, preparing a curriculum vitae, evidence-based medicine, literature searches, issues in healthcare policy, patient safety and medical errors, and globalization of health care. The remainder of the rotation (with patient care responsibilities at night) is devoted to preparing and carrying out a required scholarly academic project. Residents are given flexibility to develop a project that overlaps with their career interests. Residents have emphasized clinical research and curricular innovations, although a smaller number have focused on basic science projects. All projects require a faculty mentor. At the beginning of the rotation residents are required to submit a charter outlining their goals and project plans. A completed project is an explicit expectation.
Early implementation of projects in the PLII year and mandatory participation in a preparatory workshop have optimized effective use of the rotation. Faculty mentors have been helpful in obtaining in-kind divisional support (technician time, secretarial time, scientific expertise and funding). Examples of recent projects include protein signaling in malaria infections, hospitalist management of common pediatric illness, a medical ethics curriculum for pediatric residents, and car seat use in newborns.
The departments provide residents with financial support ($400 to $750 per grant) to attend academic national meetings to present their work (a steadily increasing number of residents have presented posters and platforms at the Pediatric Academic Societies meetings over the past 5 years: 4 in 2003, 5 in 2004, 6 in 2005, 12 in 2006, and 9 in 2007) and to publish their research in peer-reviewed journals.
Special Research Tracks
In the mid 1970s, the American Board of Pediatrics established the Special Alternative Pathway (SAP) to shorten the time between medical school research and subspecialty training. With the number of subspecialists decreasing in the mid 1990s, the Board also established the Accelerated Research Pathway (ARP), as well as the Integrated Research Pathway (IRP).
Over the past 18 years (1990–2008), 35 residents from our program with prior research experience have used these 3 pathways (SAP [n = 24], ARP [n = 7], IRP [n = 4]). The subspecialties pursued have included 17 into hematology/oncology, 4 each into immunology/rheumatology and cardiology, 3 each into infectious diseases and endocrinology, 2 each into neonatology and genetics, and 1 each into gastroenterology and critical care medicine. Two residents have pursued combined fellowship training.
Selection of residents occurs in the PLI year and is based on a track record of excellent research and a future trajectory of clinical laboratory-based investigation. It is further based on In-Training Examination scores and clinical performance in the upper one-third of the intern class. The numbers able to pursue special tracks after the first year (IRP) and after the second year (SAP and ARP) are carefully considered. A program structure with decreasing residents in each of the 3 years, as well as an outside pool of candidates, ensures optimal resident numbers in a year when many wish to pursue special tracks. For IRP residents the selection of a laboratory focused in the area of a resident's prior work is critical and must be coupled with the laboratory's capacity to fund the residents' research time. For those pursuing the ARP, funds must be ensured for 4 years of fellowship training.
Program adjustments are relatively few: continuity clinic in the first year of fellowship for SAP residents, increased supervisory time in the PLII year for ARP residents, and resident coverage of rotations when IRP residents are doing research (part-time residents or “off cycle” residents who begin in January of a given year). Program needs (optimal number of residents per year) must be balanced with individual resident's career desires.
Advantages to the use of special tracts include (a) earlier return to an academic career for an individual resident; (b) an enhanced focus on biology and science at resident conferences; (c) creation of a dynamic culture of resident to resident education by merging residents with diverse interests on clinical teams; and (d) enhancement of subspecialty faculty involvement as mentors and research advisors. Disadvantages include (a) 2 rather than 3 years of general pediatric training; (b) missing the PLIII year with its focus on leadership and supervision; and (c) modification of resident schedules to meet the requirements of the American Board of Pediatrics.
Financial Support for Research and Academic Careers
Many articles indicate that funding support for resident research and travel is necessary, but few describe its generation or distribution.6 Over the past 10 years our program has generated funds specifically for residents to support their research projects. At Children's Hospital the Fred Lovejoy Resident Research and Education Endowment has been created by alumni, faculty, foundations, and friends of the residency. Spearheaded by the department chair, program director, and the hospital's development office the fund is managed as part of the hospital's endowment and generates approximately $40,000 of income yearly. Over 4 years since the inception of the endowment, 31grants (approximately $4000 per grant) have been awarded for a totaled $120,000. More than 100 alumni have given to the endowment, and special friends, hospital clinical departments, and Boston-based foundations have been particularly generous. At Boston Medical Center the Barbara and Joel Alpert Children of the City of Boston Endowment, was created more than 10 years ago to support the academic activities of junior faculty, fellows, and pediatric residents. Generated from a similar group of donors, this endowment provides annual total funding of approximately $50,000. Since its inception the fund has awarded 21 of 82 grants to pediatric residents with the awards ranging from $400 to $8000 for a total of $92,000.
Residents apply to both endowments through a formal application process. All applications must have the involvement and support of a mentor. The selection criteria include the scientific quality of the project, as well as research that supports the mission of both institutions. Faculty committees that include clinical and basic investigators, medical educators and program directors review and select the projects to be funded. Approximately 50% of the submitted applications each year are funded. Supplemental funding from other sources is encouraged. Funds may be spent for laboratory analysis, questionnaires, programmer costs, data analysis and travel but not for faculty or resident salaries or permanent equipment. Progress reports at the end of each year are required.
Of the 31 Lovejoy awards, 19 have been given for clinical, 6 for basic, and 6 for educational research. Residents in all 3 years of the program may apply and have been successful recipients. Grants have resulted in 17 (55%) abstracts presented at national meetings and 9 (30%) studies published or under review. Only 4 (13%) have failed to reach completion. Residents have been recognized as recipients of the Resident Research Award and the Helfer Award. Of the 21 Alpert awards, there have been 8 presented abstracts and 6 published manuscripts.
Mentors and Advisors
In 2001, the American Academy of Pediatrics developed recommendations for enhancing research during pediatric residency training, including ensuring access to research mentors.7 Steiner et al,8 surveying 10 years of graduates of National Research Service Award-funded primary care research programs, identified 3 important domains of mentorship: the relationship between mentor and fellow (such as guidance and support); professional attributes of the mentor (such as reputation); and personal attributes of the mentor (such as availability and caring). They concluded that ongoing support of mentors is critical to support the research activities of trainees.8
Within our program each resident is assigned an advisor during orientation week. This relationship is designed to foster a smooth transition into the residency program. Advisors, however, do not necessarily serve as the resident's mentor. Over the course of their training, residents declare academic interests that require the input of mentors either for career decisions or to serve as mentors for academic projects. With broad resident and faculty input, a core group of faculty has been selected as mentors. Faculty with success as mentors are used preferentially for subsequent research projects. Department Chairpersons highlight the importance of this role during annual review and during times of proposed academic promotion. The careers of faculty mentors are enhanced by (a) working with talented residents who may have similar career interests; (b) projects leading to successful publication; and (c) active mentoring being beneficial in the promotion process.
References available at www.jpeds.com.
References
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- . Research during pediatric residency (Predictors and resident-determined influences). Acad Med. 2003;78:1253–1258
- . Resident research in internal medicine training programs. Ann Intern Med. 1996;124:321–328
- . Initial successes and challenges in the development of a pediatric resident research curriculum. J Pediatr. 2006;149:149–150
- . Research exposure during pediatric residency: Influence on career expectations. J Pediatr. 2003;143:564–569
- . Impact of a residency research program and research activity, faculty involvement and institutional cost. Teach Learn Med. 2005;17:159–165
- Promoting education, mentorship, and support for pediatric research. Pediatrics. 2001;107:1447–1450
- . Assessing the role of influential mentors in the research development of primary care fellows. Acad Med. 2004;79:865–872
The opinions expressed herein by the authors do not necessarily reflect the official endorsement of The Association of Medical School Pediatric Department Chairs, Inc.
PII: S0022-3476(08)00103-0
doi:10.1016/j.jpeds.2008.02.007
© 2008 Mosby, Inc. All rights reserved.
