Improvement of Resident Scholarship in an Internal Medicine Training Program

The Accreditation Council for Graduate Medical Education (ACGME) stipulates that residents must participate in scholarship, and programs must provide curricula to accomplish this. Residents understand that they should participate in scholarly activity, but are often dissatisfied with their program’s approach. Evidence of effective interventions that lead to tangible scholarship in 3-year residencies is inconsistent. Recent systematic reviews have described initiatives utilized by ACGME programs to increase scholarship. Tripler Army Medical Center (TAMC) Internal Medicine (IM) residency program educates a diverse group of civilian and active duty military residents. We initiated simple, reproducible interventions to improve resident participation in and understanding of the medical research process, based on previously published methods.


INTRODUCTION
The Accreditation Council for Graduate Medical Education (ACGME) stipulates that residents must participate in scholarship, and programs must provide curricula to accomplish this. Residents understand that they should participate in scholarly activity, but are often dissatisfied with their program's approach. 1 Evidence of effective interventions that lead to tangible scholarship in 3-year residencies is inconsistent. Recent systematic reviews have described initiatives utilized by ACGME programs to increase scholarship. 2,3 Tripler Army Medical Center (TAMC) Internal Medicine (IM) residency program educates a diverse group of civilian and active duty military residents. We initiated simple, reproducible interventions to improve resident participation in and understanding of the medical research process, based on previously published methods. [2][3][4][5][6] METHODS As a process improvement study, a structural framework was developed for scholarly activity within the TAMC IM residency program. A total of 32-39 IM residents per year participated. The interventions took place at the start of the 2016-2017 academic year. Metrics were collected from July 2016 to June 2019. Metrics from July 2015 to June 2016, before interventions occurred, served as the control. No additional monetary funding was provided.
A Scholarly Activity Council (SAC) was assembled, with a volunteer faculty member serving as Chair (CSAC). The council contained representatives from each IM subspecialty, to act as human resources for projects in their area of expertise. All SAC members were volunteers. The CSAC created a shared access database, including a bulletin of projects needing assistance, deadlines, and a list of project statuses and pending tasks. It was reviewed and updated monthly at a dedicated research conference on the academic schedule, where residents also practiced presentations and discussed projects. Faculty members in attendance at the meeting could give feedback and advice for these presentations or projects. A research curriculum was designed, including monthly lectures on statistical analysis, critical literature appraisal, and guides for manuscript writing. Protected longitudinal research time was added to resident schedules, with 4 weeks of dedicated time per academic year. This time replaced one elective rotation block.
From July 2016 to June 2019, residents were requested to report any new scholarly activity to the Chief of Medical Residents. Metrics collected to evaluate participation included quantity and type of manuscripts published, presentations at local/regional/national conferences, and ongoing or new Institutional Review Board (IRB)-reviewed studies. Abstracts' or manuscripts' pending acceptance and in-house scholarship, such as morning report or grand rounds, were excluded.

RESULTS
From July 2015 to June 2016, 4 manuscripts and 2 book chapters were published, and 22 presentations were given. This represented the program's baseline scholarly activity. During the 2016-2017 academic year, presentations increased to 45 (Table 1). This increase remained stable, with overall 186% growth over 3 years. Accepted peer-reviewed manuscripts surged to 8, and then 14. This represents a 350% growth from the initiation of interventions. In June 2016, an

DISCUSSION
Scholarship increased within the TAMC IM residency program after instituting reproducible, evidenced-based interventions 2-6 requiring minimal resources. Overall, the interventions described established a collaborative environment between faculty and residents ( Table 2).
Other programs have utilized similar interventions to improve scholarly activity. [2][3][4][5][6] Among primary care specialties, lack of mentorship and protected time to complete scholarship impacts their ability to fulfill the requirement. 4 Other factors, e.g., prior research experience and desire for fellowship training, may also affect scholarship. [1][2][3][4]6 Our project presents a standardized, literature-derived approach that is transferable across ACGME programs.
Limitations include a small sample size and limited preintervention data. It is difficult to quantify which aspects of the multi-pronged interventions were most successful, and to what degree the culture change, signaled by an overt focus on scholarship, augmented the individual interventions. We posit that the cumulative effect of the interventions outweighed the sum of their parts.
By developing a stable research environment with designated mentors, we increased our production of peer-reviewed publications. Key to the success of the program was the designation of the CSAC, who was empowered to make substantial, meaningful changes. Further work is needed to evaluate how other specialties may benefit from similar interventions, and to refine further the approach to scholarship across ACGME programs. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons. org/licenses/by/4.0/.