Cultural Influences Catalyzing Resident Scholarly Productivity

A goal of the scholarly activity core requirements set by the Accreditation Council for Graduate Medical Education (ACGME) is for all residency programs to develop critical thinking, learn critical appraisal of the medical literature, and foster lifelong learning. ¹ Within family medicine, residents should complete two scholarly activities, including a quality improvement project, and disseminate this scholarship prior to graduation. ² Prior research documents several recognized barriers to accomplishing resident research, including lack of protected time, training, mentors, administrative support, presentation venues, and funding. ³ Due to these constraints, avoiding resident perception that scholarship is simply an additional requirement can be difficult.

To overcome these barriers, residencies have implemented interventions, including mentorship, providing protected time, and delivering didactics. ⁴ The Naval Hospital Jacksonville Family Medicine Residency program developed and implemented a primarily resident-driven scholarly activity curriculum, which resulted in a significant increase in scholarly activity and resident participation. ⁵ That curriculum included designating a resident research coordinator as a peer leader for scholarship, implementing an introduction to research basics case report workshop, ⁶ and sharing a scholarly activity guidebook. ⁷ Secondary changes included the institution of a scholarly activity point system, ⁸ prominent exhibition of scholarly activity in organizational hallways, intentional mentorship from faculty, ⁹ and frequent reminders of upcoming venues for research dissemination. Finally, increased networking and infrastructure from programs like the Military Primary Care Research Network (MPCRN) and the Council of Academic Family Medicine Educational Research Alliance (CERA) ¹⁰ were used to provide opportunities for intraprogram collaboration and sharing of resources. This success was then replicated at Eglin Family Medicine Residency, which is a 12/12/12 fully accredited program with 14 faculty nestled within a community military hospital as an unopposed residency. Application of this curriculum led to a documented 302% increase in conference presentation submissions compared to the previous 3-year average and a 91% increase compared to the preintervention year. ¹¹

Across multiple programs, a similar theme has been noted: Implementing a wide array of interventions to foster scholarly activity increases production. ⁴ Indeed, Wood et al’s systematic review of 32 articles on initiatives to increase graduate medical education (GME) scholarly activity concluded, “A culture of emphasis on resident scholarship is the most important step.” This finding suggests commonalities underlying the nature of specific interventions. While Eglin’s scholarship output change was evaluated quantitatively, the second and fourth authors, who were present during the change, also sensed a culture shift in how scholarly activity was perceived and integrated in the residency. Focusing on the elements contributing to this cultural change, we conducted a qualitative study to determine what interactive elements existed during the observed period of increased scholarly productivity. Additionally, we wondered whether a penumbra of scholarship extended beyond residency participation. Did graduated residents, now attending physicians, persist in their scholarly pursuits?

Using a grounded theory approach, we designed and implemented a qualitative study to develop a model of influences that impacted resident scholarship after a period of curricular intervention. This study was deemed exempt by the Wilford Hall Ambulatory Surgical Center Institutional Review Board (IRB). For the purposes of this study, we defined scholarship as research or scholarly activity to include authoring peer-reviewed and nonpeer-reviewed articles, presentations, or chapters; or conducting Institutional Review Board–approved projects including research studies or exempted process or quality improvement projects. The terms research and scholarly activity were used interchangeably and usually together when interviewing participants.

Our primary research questions sought to explore the influences on residency scholarship’s quantity and quality at Eglin’s program during the years 2016 to 2019. We developed a subsequent secondary research question to understand how these influences impacted a residency graduate’s motivation to accomplish scholarship beyond graduation. That question explored the persistence, or its lack, of motivation beyond graduation from the residency milieu. Our three research questions were:

• Why did the quantity of scholarly research increase between 2012 and 2018?

• Why did the quality of scholarly research increase between 2012 and 2018?

• How did this (these) intervention(s) affect resident motivation for scholarship beyond graduation?

We purposively sampled both high- and low-producing residency graduates and faculty who were at the program during the time of increasing scholarly productivity. We defined high producers as residents who produced three or more high-quality projects, which included IRB-approved projects and/or peer-reviewed publications. Low producers were those who met the minimum ACGME requirements of two scholarly activities. We did not quantify faculty output into high- and low-performing groups. The interviewer role was shared by all four authors. We chose this approach to enable a robust discussion about the emerging data. The interview was structured by a guide (Table 1 ) with two demographic questions and 12 open-ended questions, including additional probes as applicable. Topics included overall impressions of research, the program’s scholarly activity levels, and facilitators and barriers to scholarly activity. As data was gathered, we revised our interview guide using the constant comparative method, ¹² combining data collection with data analysis. Our research team met three times to identify core codes and to revise our probes to capture emerging information from the next set of participants.

We completed 17 interviews (three from the graduated class of 2017, four from the graduated class of 2018, and five from the graduated class of 2019; and five faculty interviews). The sample included a mix of six high and five low resident producers of scholarly activity. One resident graduate interview did not fit either the high or low producer category. Interviews resulted in 6 hours and 7 minutes of data collected, or 98 pages of transcribed text. The shortest interview lasted 11 minutes and 38 seconds. The longest interview lasted 27 minutes and 9 seconds.

The first, second, third, and fourth authors met to explore emergent core codes. Once we reached saturation of our core codes, we developed our codebook and then set about axial coding. Axial coding consists of identifying recurrent core codes, extracting the conceptual relationship within these recurrences, naming, and then applying this secondary order or axial code to the data. After we completed axial coding, we next developed a relational theory detailing these thematic factors. Finally, the authors developed a grounded theory to describe the interplay of these factors. To validate our findings, three research participants reviewed and approved our axial codes.

We found five elements or themes influencing the residency’s culture of increased scholarship productivity. Those themes were mentorship availability, interest/opportunity alignment, research mechanics demystification, leadership support affecting productivity, and scholarship begets scholarship (Table 2). We noted that these elements fostered scholarship at the individual level (mentorship, interest/opportunity alignment), the program level (research mechanics demystification), and the sponsoring institution level (leadership support affecting productivity). We realized that these levels underscored the comprehensive multilevel cultural change present during the residency’s transformation.

Mentorship availability increased both the quantity and quality of scholarship. Importantly, participants commented on the presence of both faculty and resident mentors. Mentorship often led to a better understanding of the research process and provided a means for interest/opportunity alignment. Mentorship occurred between and among both residents and faculty.

Participants repeatedly commented that advertising opportunities led to the discovery of shared interests that then seeded collaboration. Often these opportunities flowed between mentors, but we noted that informal and formal mentorship networks invariably developed when advertised opportunities provided shared interest expressed through collaboration.

When the program demystified the scholarly work process by providing instructions and resources, scholarly productivity increased. Participants expressed that mentors were important as resources to demystify perceived barriers.

Participants reported that leadership support, through verbal and nonverbal cues, affected production. Leadership support fostered mentorship (through verbalized formal relationships) as well as research mechanics demystification through nonverbal cues including curricular support and resource allocation for conference attendance.

Participants depicted a cultural connection of norms and behavior, describing how scholarship begets scholarship. Participants observed that scholarship involvement motivated further scholarship involvement by modeling project completion.

As described earlier, mentorship availability, interest/opportunity alignment, research demystification, leadership support, and scholarship begetting scholarship all emerged from our interviews as contributors to culture development. Notably, all five themes were present among high/low performers and also were noted by faculty, suggesting how these themes expressed the development of a new culture of scholarship.

Moreover, these individual cultural elements interacted in intriguing ways. For instance, the availability of mentorship grew as more and more faculty and residents gained scholarship experience. As scholarship begot more scholarship, more opportunities emerged, leading to increased opportunities for residents to find opportunities aligned with their personal interests. Furthermore, the residency leadership provided support through formal education sessions and outside resources, which demystified the mechanics of research. This support, in turn, led to lowering barriers and fostering better participation, which in turn created the conditions for further mentorship, which then led to prior scholarship begetting future scholarship. As we considered the residency’s cultural change, a theory of this interaction began to emerge. We conceptualized the interaction visually as a planetary gear where the middle (or sun) gear spins the rest of the individual gears (Figure 1).

The complexity of our model points to the known interrelated nature of any cultural change. As the apparatus builds up speed, all elements must interact to spin faster and faster. The structure is not hierarchical because all elements must interact to spin the wheel. As the mechanism spins faster, it is dependent on its inner cogs to maintain velocity. Thus, if an institution has more scholarship, opportunities for mentorship and interest/opportunity alignment are greater. Moreover, the rate of the spin is limited by leadership support as well as research mechanics demystification. If additional resources are not provided, the rate of scholarly productivity is inhibited because the limited speed of any one element deleteriously impacts the speed of the others. Conversely, if leadership provides resources but no mentors and few opportunities, the mechanism will not turn faster.

We found further support for this interaction from graduated residents’ experiences with scholarly activity after residency. Interestingly, while numerous graduates expressed motivation for scholarly activity participation after residency, few actually participated. Beyond residency, our research indicated that motivation to continue research was maintained but that organizational factors often precluded participants from continuing scholarly activity. When asked about whether they had continued mentoring others in scholarly activity beyond graduation, one residency graduate (residency grad 4) in a nonacademic job responded, “No, I would love to but this just isn’t the place for it, because, um, yeah, everybody is just so tired. I don’t know. I’ll be honest. It’s just there’s no time for it, you know. It just goes by the wayside.” When asked about plans to engage in future research or scholarly activity, another (residency grad 2) reported, “openness to other research, yes. But no specific plans at this point. No, because I’m moving. . .. I don’t know the environment there and I don’t have a specific research question, but I’d be open to it, if something sort of fell into my lap or if an interest developed.” These comments suggested that interest alone was inadequate to accomplish scholarly activity, indicating that more than this was needed to sustain productivity.

Our findings suggested that the standard interventions of a resident research coordinator, a case report workshop, and a research guidebook fostered culture change and were not individually the main cause of the observed increased scholarly productivity. We suspect that implementing multiple interventions caused the cultural changes that fostered the scholarly productivity. The importance of multilevel interventions described in our study demonstrates the validity of prior work, which recommended that multiple interventions are needed to overcome real and perceived barriers to resident scholarship. ¹³ Additionally, our observed cultural elements (mentorship availability, leadership support, interest/opportunity alignment) have been previously described as bright spots in other successful family medicine research. ¹⁴ Our model also may explain why these other interventions have proven effective. ^{4, 14} The success was not the result of the interventions themselves, but rather from the multilevel culture changes they created. In other words, the interventions synergistically drove culture change. This cultural change reduced uncertainty about accomplishing the scholarly activity requirement and thus increased mentorship, which promoted resident scholarship productivity.

Ours is the first study to qualitatively assess cultural contributing factors experienced by participants during a period of significantly increased scholarly productivity at a community-based family medicine residency. Although our study’s findings are bound to this setting, the cultural elements of mentorship, leadership, scholarship opportunities, and scholarship instruction have been observed in other settings, including medical schools ¹⁴ and other subspecialty residencies. ^{4, 15} Our model proposes that multilevel interventions, as opposed to focusing on individual elements, will lead to increased scholarship through cultural transformation. Further, we contend that building such productivity hinges on fostering a synergistic interaction among multiple supporting elements.

While the precise interface and proportionality of each cultural element will differ from institution to institution, knowledge that such interactions existed in our resource-limited community-based military residency program and led to increased scholarship may prove helpful in other settings. Instead of resourcing one element exclusively, a residency program will likely find greater success by dividing limited resources to promote the individual elements (increasing mentorship, aligning resident interest with opportunities), the program element (demystifying research), and the institutional element (leadership support).

Our findings and emergent model must be considered within its original context.

Although we captured a diverse set of resident experiences by sampling from different class years with both high and low scholarly productivity, we did not interview all residents and all faculty during the study time frame. Thus, some perspectives may not be incorporated into our research. Also, we struggled to delineate between factors that increased quality versus quantity. The nature of our structured interviews lent themselves better to evaluating greater scholarly involvement as opposed to delineating the quality of such involvement. Although we observed factors that increased scholarly activity, we had difficultly determining whether such factors increased quantity or quality, or both. Future work in this area of research would involve exploring the presence and absence of these multilevel factors and their interactions in other settings that have experienced similar scholarly productivity increases. Such an approach would further refine our proposed theory of resident scholarship productivity.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Department of the Air Force, the Department of Defense, or the United States Government.

Funding support was provided through a grant from the Uniformed Services Academy of Family Physicians (Grant number: #18 LG-1).