Encouraging scholastic publishing by urologic trainees.

THERE ARE MANY REASONS WHY UROLOGIC TRAINEES SHOULD PUBLISH SCHOLARLY WORK: Personal, professional, and institutional. Publishing by trainees creates an environment that improves the specialty of urology, maintains the quality of our literature, and promotes professionalism of our practitioners. Strategies to encourage scholastic publishing distil down to providing recognition, time, and support to the individual trainee.

The current training environment for surgeons in the United States and in many parts of the world conspires against a young trainee's ability or desire to contribute to the academic literature. Increasing demands on a trainee's or mentor's time, dwindling administrative support, elimination of dedicated research time, and lack of research funding are just a few barriers. Despite these challenges, a recent survey of current and recent urology residency graduates in the United States reveals that urology residents write an average of three papers during their training with two having been published.[1] Yet before any discussion on strategies to promote publishing by urology residents and fellows is undertaken, it would be valuable to outline the arguments as to why all urologists in training should prepare and attempt to publish a manuscript even those uninterested in a career in academic medicine.

There is a paucity of contemporary objective data to support the contention that publications by a resident or fellow is beneficial for their development as a clinician or results in improved patient care. However, there is some older literature that describes an association between resident publications and improved patient care in non-urologic clinical disciplines.[23] Regardless of a societal benefit, it is my belief that every trainee for personal development as a surgeon should prepare a manuscript – whether a peer reviewed article, book chapter, or other monograph.

One can trace the transition of medical training and academic medicine from a loose confederation of apprenticeships to a profession overseen by governing bodies in the early 20th century following the Flexner Report. The Flexner Report reviewed medical schools and other training programs in the United States and set the foundation for modern academics.[4] The realization that peer-reviewed publications enhance patient care by disseminating information on the pathophysiology of disease, determining the optimal evaluation of a patient, ascertaining effective therapies or merely reviewing these concepts for the practioners seems self evident and not discovered by Flexner. In this regard, the trainee may be the bottom of the feeding chain in contributing to the explosion in medical literature. Then why not leave medical writing to the experts? Given restrictions on resident and fellow work hours, would precious time be better spent in direct patient care and clinical competencies than an assignment to write a paper, chapter, or thesis? If only 6% of US urologists are full-time academics, then why does the average trainee need to bother writing something that few may read and has which limited or little impact on patients or scientific discovery? Yet a perusal of program descriptions posted on internet reveals that nearly every US residency program and all fellowships mandate at least one publication as a criterion for the successful completion of training. Why? The simplest explanation is that the Accreditation Council Committee on Graduate Medical Education (ACGME) requires all accredited urology residents to advance knowledge of basic principles of research and how research is applied to patient care.[5] Performing a small research study, writing up a case report or reviewing the literature, and documenting a manuscript is an outcome measure that meets this requirement. But program directors can design less time-consuming and rigorous means to meet this requirement.

Let me review my personal reasons for believing that as educators we must encourage publishing by trainees in the absence of any study supporting these contentions. First, the trainee must appreciate what is known and unknown in medicine to be a better doctor. While journal clubs, teaching rounds, seminars, or symposia can highlight current knowledge they are not substitutes for the rigor imposed by sitting down and articulating arguments for or against a hypothesis, diagnostic test or treatment on paper and then convincing a reviewer or faculty member of this stance. Second, the demands of writing well are appreciated early in secondary education by most trainees but forcing them to obtain a publication and going through all the steps in getting a manuscript published serves a useful role in deciding on a career in academics vs. community practice. The majority of medical students entering urology residency have not published a paper. In this regard, probably the greatest barrier to entering the academic profession today is not financial remuneration, obtaining a grant, or demands of teaching and working in a university environment – it is writing and the volume that must be done to have a successful academic career. Having a resident exposed early in their training and go through the difficult process one or more times often helps in their career choice. Third, for those individuals wishing to obtain a quality fellowship or academic appointment, record of publishing is essential to obtain a competitive position. Fourth, an appreciation for the process of publishing will help in the critical assessment of the medical literature and lifelong learning that must occur throughout the career of an urologist to make clinical decisions in a rapidly changing medical environment. Indeed, a clinical competency required by ACGME is system-based learning. Although classes in statistics and medical research are of value, nothing supplants doing. By analogy, reading about surgery is not the same as performing an operation. Fifth, writing a manuscript with a faculty member if properly orchestrated establishes a close interaction not usually achieved by even one-on-one teaching in the clinic or operating room. The trainee picks up nonverbal cues regarding such issues as research ethics and care for human subjects. Such mentoring will hopefully improve overall writing skill for trainee and hopefully foster an appreciation of the time and resources necessary for high-quality clinical or basic research. This knowledge is valuable regardless of career path. Lastly, if the trainee chooses an academic career then there is a high correlation with academic productivity and grant awards with the number of publications as a resident[6] among other variables. Interestingly, there is little correlation with number or even any publications as a medical student and or numbers of publications as a resident.[6]

These arguments for trainee development are not the sole reasons that may encourage academicians to allow publishing by trainees. There are self-serving motives as well. Writing with the trainee may make the teacher a better writer and uncover unconscious biases. Trainees keep the professor honest. Questioning why certain data is or, more importantly, is not included in the report challenges the team to identify biases or scientific arguments. Little data exists, mostly in primary care and radiology literature, that shows that academic productivity and reputation of a department is positively correlated with the number of residents and fellows by virtue of either being the work horses or by stimulating discussions culminating in publications.[7] Although many expected the 80-h work week ruling for residents in the US instituted in July, 2003, to reduce faculty productivity, objective data on publications or relative value unit work production does not support this claim.[8] Thus, we in academic departments benefit from trainees who publish.

Based on these arguments and given the current challenges in academic medicine we must continue to promote and encourage our trainees to publish. This can be accomplished in several ways. A common method of encouragement is to deny documentation of completion of training unless the trainee's number of publications is met. Resident and Fellow handbooks, policies, and the curriculum outline should clearly define expectations on entering the training program. Such a prescriptive approach works, but fails to insure quality. The best way to encourage trainee publication is to create an environment in which scholarly work is valued, celebrated, and rewarded. Plus, the infrastructure should be in place to facilitate writing for the busy trainee. Trainees should have access to online journals, computers, and word processing programs especially that incorporate autocorrect software to ease the burden of writing. Regularly scheduled research meetings with one-on-one access to the senior author create timelines and develop the habit of writing even in a busy department. Residents and fellows always appreciate quality time with a faculty member. If all the residents discuss their work and papers especially if the publications are reviewed at journal club, a certain sense of pride and expectation develops. In one famous US Urology department, the competition among residents to see who wrote the most papers was well known when I was in training. This expectation trickled down to the level of medical students who understood, matching in that program meant writing. Most programs reward submission of manuscripts and abstracts with trips to meetings or annual resident/fellow research awards. Aligning the trainee's passion with the topic of the scholarly publication is paramount. Best is the trainee who presents with an idea for a paper or research study. The clever mentor finds a way to cultivate that desire into a manuscript. Most trainees are searching for a topic and choose from a menu of potentially interesting projects.

While these tactics may be of benefit, the strongest predictor of publishing by trainees is the creation of dedicated time for scholarly work or research. In the US survey of resident publications, the highest predictor of papers was a dedicated research year for research.[1] The numbers of paper published within a stipulated time was directly proportional to the allotted dedicated time for research. For example, if three or six months of time was allotted for research (n = 3), then the number of papers jumped to seven if 12 or more months was dedicated to research. Thus, it is unfortunate that most US programs have eliminated the research year. However, some time appears better than none.

Most clinicians choose a specialty because a particular individual served as a role model. The same is true of writing. A faculty mentor is essential in the writing process. Most of us in academics can readily identify the individual who taught us scientific writing as readily as recalling who taught us to operate. Writing and research mentorship demands time, patience, altruism, skill, and hard work. One learns early that the bar varies among journals as to the quality of work required for publication. The reason that rejection can undermine the self-confidence of trainees, the mentor should realistically match the level of research or quality of review with the target journal. As an editor of a major journal, it is distressing to reject a manuscript first authored by a resident because it was inappropriate for the journal (e.g., case report or small case series from single institution with little novel information). Many departments hire medical editors or schools of medicine offer assistance in terms of courses and logistical support. The skilled mentor must balance the demand for perfection with the frustration of draftorrhea. For the grammatically challenged trainee, a focus on figures or imbedded videos could provide just the incentive to labor on when the text written gets bogged down.

A mentor during my residency often reminded me of the immortality of the written word. Once published in the world literature for all to read, it remains there languishing for generations of journal clubs to critique. The value of this process toward writing perfection to the average trainee may be in the end, an appreciation that not all reports or journals are created equal. Just because something is published does not mean that the reported test or procedure should be immediately accepted and incorporated into practice just because it made it into the medical literature. The rapid rise in online internet publishing and open access will serve to amplify the written word making it accessible by a global community of clinicians and non-clinicians. Perhaps e-publishing on the internet may be attractive to the current generation of trainees reared on Youtube, MySpace, and FaceBook.

Thus, there are many arguments for urologic trainees to publish scholarly work – personal, professional, and institutional. Publishing by trainees creates an environment that improves the specialty of urology, maintains the quality of our literature, and promotes professionalism of our practitioners. Strategies to encourage scholastic publishing distil down to providing recognition, time, and support to the individual trainee.