Abstract
Introduction
Given the importance placed on awareness and participation in research by Speciality and Training organisations, we sought to survey Scottish trainee attitudes to exposure to research practice during training and research in or out of programme.
Methods
An online survey was distributed to core and specialist trainees in general surgery in Scotland.
Results
Over a 4-month period, 108 trainees (75 ST/SPRs and 33 CTs) completed the survey. In their current post, most were aware of ongoing research projects (77%) and 55% were aware of trial recruitment. Only 47% attend regular journal clubs. Most believe that they are expected to present (89%) and publish (82%) during training. Most (59%) thought that participation in research is well supported. 57% were advised to undertake time out of programme research, mostly by consultants (48%) and training committee (36%). Of the 57 with time out of programme research experience, most did so in early training (37%) or between ST3-5 (47%). 28 out of the 36 (78%) without a national training number secured one after starting research. Most undertook research in a local academic unit (80%) funded by small grants (47%) or internally (33%). Most research (69%) was clinically orientated (13/55 clinical, 25/55 translational). 56% of those completing time out of programme research obtained an MD or PhD. About 91% thought that research was relevant to a surgical career.
Conclusions
Most trainees believe that research is an important part of training. Generally, most trainees are exposed to research practices including trial recruitment. However, <50% attend regular journal clubs, a pertinent point, given the current ‘exit exam’ includes the assessment of critical appraisal skills.
Introduction
Awareness of advances in practice and keeping up-to-date with medical research is recommended by the General Medical Council’s (GMC) guidance ‘Good Medical Practice’. 1 UK postgraduate specialty training guidelines state that trainees are required ‘to understand the value and purpose of medical research and develop skills required to critically assess research evidence’. 2
In General Surgery, specific curricular objectives include the development of professional skills in appraisal and awareness of research practice. 3 It is suggested that these skills are attained through attendance at journal clubs and scientific meetings during clinical training rather than a formal research period. 3 Furthermore, the Joint Committee on Surgical Training recently issued guidance on research competencies required by trainees for the award of Certificate of Completion of Training: three peer-reviewed papers (not case reports) in indexed medical journals and three first author presentations at national conferences. 4 Ultimately, the current ‘exit exam’ in surgical training, the FRCS, includes an assessment of critical appraisal skills.
Surgery has always been a competitive speciality with an oversubscription of applicants to training posts. Although not an essential, participation in research projects and the undertaking of a designated period of research has generally been encouraged. A 2005 statement by the Society of Academic and Research Surgery (SARS) and Association of Surgeons of Great Britain and Ireland (ASGBI) enforced this view recommending widespread participation of trainees in research. 5
Surgical training is delivered over 8 years between core-training years 1 and 2 and speciality training years 3 to 8, during which, trainees rotate through various clinical settings, some opting to partake in time-out-of-programme (TOOP) research or academic training. Given the importance placed on awareness and participation in research by Speciality/Training organisations, we sought to survey attitudes of Scottish surgical trainees towards research. We designed a survey to gauge attitudes to exposure to research practice and methodology in their clinical training posts as well as their attitudes and experience of a formal period of research in/out of programme.
Methods
This national survey was a pilot study designed and distributed by the Scottish Surgical Research Group, a collaborative recently formed to facilitate trainee-led clinical research across Scotland.
Survey of Scottish surgical trainee attitudes towards research, section 1.
Survey of Scottish surgical trainee attitudes towards research, section 2: for trainees undertaking a period of research.
The survey was open between June and September 2012, during which time, participation was encouraged locally. Once closed, data were exported anonymously for analysis. Statistical comparisons were made using Chi-square test for trend of Fishers exact test as appropriate using SPSS software (SPSS and IBM Inc Version 19).
Results
In June 2012, the survey was emailed to all 181 General Surgery Speciality trainees (ST/SPR) and 58 Core trainees (CT) in Scotland. Total numbers for ST/ SPRs were 87 West, 50 South-East, 26 North and 18 East. There are 20 CTs in the West and 38 CTs on the common East-of-Scotland rotation. In total, 108 trainees (75 ST/SPRs and 33 CTs) completed the survey; 52 (48%) based in the West, 24 (22%) in the South-East, 17 (16%) in the North and 15 (14%) in the East (Figure 1). Therefore, the uptake was 45% (41% for ST/SPRs, 56% for CTs).
Trainee numbers completing the on-line survey by training deanery and stage of training (n = 108).
Exposure to research practices in clinical surgery (Table 1)
When asked, ‘In your current post/unit, are you aware of ongoing research projects?’ 77% (n = 83) answered ‘yes’. Across Scottish deaneries, this ranged from 68% and 71% in the East and West respectively, to 89% and 90% in the South-East and North, respectively. Trainees were more likely to answer ‘yes’ if based in teaching hospitals compared with district general hospitals (DGHs); 82% versus 63% (p = 0.031). Results were comparable for grades (answering ‘yes’: CTs; 75%, ST3-6: 80%, ST7-SPR: 70%; p > 0.05).
When asked ‘Are you aware of surgical trial recruitment?’ 55% (n = 59) answered ‘yes’ (East: 40%, West: 44%, South-East: 60%, North 90%). Proportion answering ‘yes’ in the North was higher than other deaneries (p = 0.004). Awareness of trial recruitment was commoner if based in a teaching hospital; 68% versus 28% (p < 0.001). Results were comparable for grades (answering ‘yes’, CTs 55%, ST3-6: 56%, ST7-SPR: 50%, p > 0.05).
When asked ‘Is there a regular journal club where peer-reviewed papers are discussed?’, 53% (n = 57) stated that they did not have access to journal clubs. Journal clubs was comparable for the West (52%), South-East (54%) and North (53%) but lowest in the East (12%, p = 0.030) (Figure 2). There was a non-significant trend towards trainees in DGHs having more access to journal clubs than those in teaching hospitals (57% vs. 43%).
Response by deanery to the question: ‘Is there a regular journal club where peer reviewed surgical papers are critiqued/ discussed?’
Trainee perceptions of training committee expectations
When asked ‘Is there is an expectation you present at national/international conferences?’, most (89%, n = 96) believed that this was expected. Percentage of responders expressing this viewpoint ranged from 100% in the South-East to 65% in the East (p = 0.010). Percentage answering ‘yes’ was comparable between DGH and teaching hospitals (96% vs. 87%, respectively) and grades (CTs: 91%, ST3-6: 88%, ST7-SPR: 87%). One hundred and two (94%) had previously presented, of which, 49 (48%) stated that this resulted from work undertaken in training posts, 14 (14%) from TOOP research and 38 (38%) from work undertaken during both clinical training and research.
When asked ‘Is there an expectation to publish in peer reviewed journals?’, most trainees (82%, n = 89) believe that this is expected. Percentage of responders expressing this viewpoint ranged from 96% in the South-East to 64% in the East (p = 0.069). Percentage answering ‘yes’ was comparable DGH and teaching hospital posts (89% vs. 79%, respectively) and grades (CTs: 79%, ST3-6: 82%, ST7-SPR: 85%). Seventy-five (69%) had publication experience, of which, 34 (45%) stated that this resulted from work in training posts, 15 (20%) from TOOP research and 26 (35%) from work undertaken during both clinical training and research.
Participation in research
The majority (59%, n = 64) of the 107 responders believed that research participation locally is well supported (easy/well supported n = 9, 8%, challenging/well supported, n = 55, 51%). About 38% (n = 41) thought that research participation was challenging and unsupported and 2% (n = 2) thought that it was impossible. Percentage viewing research as well supported ranged from 79% in the South-East to 49% in the West (East 60% and North 65%). Views were comparable for grade (‘well supported’: 61% of CT1-2s, 58% of ST3-6s, 67% of ST7-SPRs) and current post (‘well supported’ 57% in DGHs vs. 60% in teaching hospitals).
Most (57%, n = 62) have been advised to take TOOP for research. About 75% of South-East trainees were advised to undertake TOOP research versus 58% in the West, 53% in the North and 33% in the East (p = 0.075). Of the 62 trainees advised to undertake TOOP, 30 (48%) received this recommendation from a consultant they worked with, 22 (36%) from the training committee and 10 (16%) from a colleague. Thirteen (12%) were advised against TOOP research.
When asked about TOOP research, 107 responded; 33 (31%) had completed a period of TOOP research, 17 (16%) were currently undertaking TOOP research, 39 (36%) planned undertake TOOP research and 18 (17%) had no plans to undertake TOOP research. About 63% of ST7-SPRs had completed research, compared with 40% of ST3-6s and no CT1-2s (p < 0.001). About 24% of CT1-2s, 12% of ST3-6s and 19% of ST7-SPRs had no plans to complete the TOOP research. About 46% of Western trainees, 46% of South-Eastern trainees, 53% of Eastern trainees and 41% of Northern trainees were undertaking or had completed a period of TOOP research.
Experience of a designated period of research
Trainees were asked about experience of designated periods of in-training research (Figure 3). Fifty-seven had undertaken such a period, 48 full-time and 9 part-time. Most undertook research in early training (37% (n = 21) prior to ST3 and 47% (n = 27) between ST3-5). Thirty-six of 57 (63%) did not have a national training number (NTN) prior to their research but 28/36 (78%) secured an NTN afterwards. Of the 51 responders, most undertook research within local academic surgical units (41/51) followed by international research institutions (7/49). Three others stated that they undertook research during teaching posts or non-academic units (w).
Response by deanery to the question: ‘Percentage of trainees by deanery who have undertaken a designated period of part or full time research?’
Most research was funded by small grants (47%, n = 27) or internally by the academic institution (33%, n = 19). Only 9 (16%) were funded by full fellowship. Two of 57 did not respond. 34 (61%) gained teaching experience and 28 (49%) obtained experience in organisation and running of undergraduate/postgraduate examinations. Three did not respond.
Most research (69%) undertaken was clinically orientated including translational research (13/55 clinical, 25/55 translational). Fourteen undertook basic science research and the remainder qualitative or educational research. Three did not answer (Figures 4 and 5).
Location of TOOP research undertaken by Scottish surgical trainees (51 responders). Type of research undertaken by trainees during a designated period of research. (55 responders).
About 56% of the trainees completing a period of research obtained an MD or PhD (14/57 MD and 18/57 PhD). Other degrees obtained included MSc (n = 2) and MPhil (n = 2). Twenty-one of 57 stated that they did not obtain a higher degree or failed to respond.
Fifty-two of 57 thought that research was relevant to their surgical career and 5/57 did not. Forty-four of 57 stated that they would continue to work in the same field as their TOOP research, and 13 stated that they would not. Twenty-five of 57 stated that they have or would hope to continue training on an academic programme following TOOP research. When asked to rate their experience of TOOP research between 1 and 10 (10 being extremely valuable), most 40/51 responders rated the experience ≥8, and eight trainees rated between 5 and 7 and three rated 3.
Sixty-one of 108 (57%) were aware of trainee-led research collaboratives in the UK and 100 (94%) stated that they would be interested in participating in a Scotland-wide trainee-led collaborative. Reasons, given by those not wishing to participate, included ‘not interested’, ‘not good source of science’ and ‘they don’t work’.
Conclusions
This study sought to gauge trainee views and exposure to research in General Surgery. These results confirm that most Scottish trainees believe that they are expected to present and publish during surgical training and suggest the ability to do so is augmented by a period of formal research. Exposure to research in clinical training jobs appears to be adequate, given most trainees (almost 80%) were aware of ongoing research projects in their department while just over half were aware of active trial recruitment. Despite the fact that most trainees thought an understanding of research practices was expected during training, experience of critical appraisal was lacking with only 50% of responders aware of regular journal clubs in their current unit.
Given guidance from the JCST in addition to statements from SARS and ASGBI make recommendations that all surgeons should undertake research,4,5 interestingly, just over half of the trainees polled were advised to undertake TOOP research by their consultants or training committee. Approximately 50% of trainees undertake a period of designated in or out-of-programme research during training, and the majority would rate this as a valuable experience beneficial to their surgical career. A period of research seems to strengthen a trainee’s portfolio resulting in a greater number of publications, and for some, a higher degree. Indeed, 78% of those who did not hold a NTN at the start of their research period obtained one thereafter.
About 63% of senior trainees (ST7 + /SPRs) have completed a period of research, an important fact for junior trainees to bear in mind when considering TOOP research given competition for consultant posts. However, it is somewhat disappointing to note that just over 50% of those undertaking a period of research had completed a higher degree, even when allowing for those still involved in research and the writing-up process.
In the last 10 years, changes in working patterns within speciality training, brought about predominantly by the implementation of the European Working Time Directive, have led to increasing complexity of trainee rotas. Shorter sessions and protected time off may partly explain the low number of regular journal clubs. None-the-less, given that trainees are examined on their ability to appraise surgical research in the FRCS exit exam, it is worth highlighting this apparent lack of journal club exposure. One potential solution to the lack of regular journal club exposure may include the use of on-line or electronic discussion boards to enable more widespread participation in discussions on research methodology and critical appraisal. Such technology may assist in meeting the educational needs of trainees spread over a wide geographical area. Alternatively, senior surgical trainees should have the necessary skills to organise and conduct research journal clubs given the wide exposure to research practices during training suggested by the present study’s results.
According to the present results, Scottish surgical trainees usually undertake research locally within an academic surgical unit rather than an independent research institution. Furthermore, most surgical research appears to be funded internally or through small grants rather than full fellowships acquired competitively through central agencies. Only 9/57 responders had been awarded a full fellowship to fund research suggesting that external funding is one area where local academic units could improve.
It is encouraging that approximately half of those undertaking research wish to continue on an academic career path. This is especially pertinent, given the recent expansion in numbers of senior clinical lecturer and clinical scientist posts (www.nes.scot.nhs.uk). General Surgery now has a higher number of academic trainees than any other specialty in Scotland. The 2011/2012 Scottish Clinical Research Excellence Development Scheme report 6 stated that there are 45 Scottish General Surgical trainees currently engaged in academic posts as clinical fellows, lecturers or clinician scientists.
These present results are in keeping with a published survey of surgeons completing a period of dedicated research in the University of Edinburgh. Of 43 responders undertaking research between 1972 and 2007, 7 35 thought that research benefitted their future surgical training but only 18 thought that research should play an integral part in training. Most of those questioned continue to pursue a surgical career in which they have a research interest.
Another study in which 91 surgical research fellows from across the UK were polled in 1999 examined the timing of TOOP research. 8 About 64% were experienced senior house officers and 32% specialty registrars at the time of research. At that time, 18% undertook purely clinical research, 43% laboratory-based and 38% translational-based research. This compares with the present studies 23% clinical, 25% lab-based and 45% translational. Although these cohorts are drawn from different time periods, one might suggest that there has been an increase in research with direct clinical relevance in the recent years.
The present study’s results are limited by the response rate of 45%. It is possible that those who responded may harbour a greater interest in research than those who did not, potentially biasing the results.
In summary, most Scottish General Surgery trainees believe that research is an important part of surgical training. A trainee-led research collaborative, similar to those established in England and Wales,9,10 may aid trainee participation in research and would be well supported.
Footnotes
Declaration of conflicting interests
There are no conflicts of interest to declare.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.