1. Resident Research and Scholarly Activity: Adding Excitement and Flexibility Laura Morris, MD Kathryn Hayes, MD University of Missouri

2. Objectives Identify guidelines and recommendations for resident scholarship Review an example of curricular change at the University of Missouri Discuss typical barriers and roadblocks Network in small groups and brainstorm possible solutions to common problems

3. Background As a resident, I was interested in research – Difficult to find time to participate – Didn’t really know how to incorporate into a resident’s busy schedule – It turns out my problem is everyone’s problem!

4. Background As a current resident, I am interested in research – Difficult to find time to participate – Didn’t know who the researchers in our department are – Struggled with how to get started

5. Background Lamentation of low scholarship in our residencies is not new – 1995 AAFP Committee on Research funded several projects aimed at increasing residents’ research experience Researchers and educators have called for increased emphasis on scholarly activity Recently, Crawford and Seehusen examined change since revisions to RRC requirements – Most programs still have limited scholarship Crawford P, Seehusen D. Scholarly Activity in Family Medicine Residency Programs: A National Med 2011;43(Survey. Fam 5):311-7

6. ACGME Scholarship falls primarily under section IV.B Residents’ Scholarly Activities but also Practice-based Learning and Improvement http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf

7. ACGME “Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care” “The curriculum must advance resident’s knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.”

8. AAFP Recommended Curriculum Guidelines Information Management and Scholarly Activity: Ask answerable questions applicable to clinical care Search, find, and appraise both primary and secondary sources for answers to these clinical questions Apply this information to the care of their patients Complete a scholarly project Revision coming soon…more specific http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/practicebasedlea rning.Par.0001.File.tmp/Reprint289C.pdfhttp://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/practicebasedlea rning.Par.0001.File.tmp/Reprint289C.pdf Accessed 3/8/12

9. AAFP Recommended Curriculum Guidelines Practice Based Learning and Improvement: Be familiar with and access information from EBM data sources Be familiar with study design and statistical methods Develop an ongoing effort to identify the best evidence for clinical issues Apply principles of evidence based medicine in clinical practice http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/ practicebasedlearning.Par.0001.File.tmp/Reprint289C.pdfpracticebasedlearning.Par.0001.File.tmp/Reprint289C.pdf Accessed 3/8/12

11. Our Program University of Missouri (Columbia, Missouri) 12/12/12 university-based program P4 participant Academic fellowship comes and goes (with funding) Residency has overall low scholarly productivity – 2009-2010 four scholarly projects (36 residents) Department traditionally has strong academic focus and dedicated, productive research faculty

12. Former MU Curriculum YearScholarship Integrated residentParticipate in multidisciplinary quality improvement (internal institutional program) R1Case conference presentation with partner R2Formal journal club presentation R3Grand rounds presentation All levelsOngoing QI curriculum QI project conceived, implemented and carried out by resident

13. Former MU Curriculum Residents interested in sports med often collaborate with faculty to publish a case report or review Rarely, a resident carries forward an undergrad project Definitely viewed by residents as “research optional”

14. Time for a change… Important things about change: – All change is perceived as loss by someone – Doctors dislike being asked to change! – Residents particularly dislike being asked to change when it may involve more work! Requested by program director – Supported by department chair

15. It is possible… DeHaven et al identified characteristics of successful research programs: – Protected time – Faculty participation in research – Access to experienced researcher(s) – Support of department chair – Research curriculum/journal club – Forum for presentation DeHaven MJ, Wilson GR, O’Connor-Kettlestrings P. Creating a Research Culture: What We Can Learn From Residencies That Are Successful in Research. Fam Med 1998;30(7):501-7.

16. Curriculum Development Stakeholder meeting: residency faculty, chief residents Decide to “require” scholarship above and beyond our current standards Notice I didn’t call it “research!” Our acronym RSA = Research and Scholarly Activity

17. Curriculum Development Boyer (1990) defined four types of scholarship: – Discovery—creating new knowledge – Integration—connecting pre-existing ideas or knowledge in a new or different way – Application—using knowledge in practice – Education—dissemination of knowledge to others Difficult to integrate, apply, or educate without an understanding of discovery!

18. Curriculum Development What unique factors exist in our institutional culture? Survey Instrument – 77% response rate (33/43) – Background – Attitudes/opinions regarding research in FM, comfort with EBM literature, future use of research/scholarship – Perceived barriers to RSA – Interest in specific curricular items and RSA track

19. Previous and current RSA activity No 67% No 70% Yes 33% Yes 30% Participate in RSA prior to residency? Current RSA participation?

20. Indicate your level of agreement… RSA is important in family medicine RSA benefits physician development I feel comfortable interpreting EBM I feel comfortable applying EBM 1= Strongly disagree 5= Strongly agree

21. Indicate your level of interest… Working on a faculty research project Creating my own research project Writing for publication Presenting my RSA project 1= No interest 5= strong interest

22. In the future, I am likely to… Perform QI Collaborate on research Initiate a research project Give a presentation Pursue grant funding Teach or precept 1= Strongly disagree 5= Strongly agree

23. Other responses included “research is intimidating,” “lack of time to travel or present” and “clinical work interferes” Check all barriers that apply… Lack of time 97% No interest 53% No barriers 0% Lack guidance 56% No funding 28% Other 9%

24. Survey summary Residents care about scholarship Residents are interested in scholarship Residents have a really hard time actually getting it done

25. New RSA Curriculum Objectives Understand the importance and relevance of research in family medicine Demonstrate a working knowledge of the research process through didactic learning, interaction with faculty researchers, and hands-on involvement in ongoing research activity Apply basic understanding of statistical analysis and statistics tools and the principles of clinical epidemiology necessary for critical interpretation of the medical literature

26. New RSA Curriculum Objectives Produce scholarly work in the domains of discovery, integration, application and/or teaching and share this work with the local, regional and national community Become competent consumers of medical literature with the ability to translate clinically relevant research into improved quality of patient care. Value the research experience gained in residency

27. New Requirements REQUIRED ELEMENTS PLUS, choose project(s) to total 4 points 4 points2 points1 point Case Conference (R1) Journal Club (R2) Grand Rounds (R3) QI project with poster (R1-R3) Completion of well- designed research project, including participation in faculty project OR Completion of additional QI project including analysis and presentation of data (poster, seminar, submission for publication, etc) Submission of peer- reviewed publication (FPIN writing project, case report, review article) OR Completion of book chapter or section OR Submission of poster/podium presentation to local, state, or national conference Publication of medically relevant article for lay public (e.g. newspaper, patient education) OR Presentation of medically relevant material to lay public (e.g. student group, church group) OR Participation in resident EBM journal club x 1

28. FPIN Scholarship Family Physicians Inquiries Network Provides scholarship opportunities for faculty and residents Evidence based medicine modules Writing for publication in Evidence Based Practice

30. FPIN Faculty Scholarship Help Desk Answer (HDA) Brief, structured answers to clinical questions Written by physicians for physicians Peer reviewed

31. Evidence Based Journal Club Editorial board for Wiley & Sons POEMs Resident participates in POEM review Presents key monthly article and POEM in a journal club style to peers

32. That is how we are doing RSA… What are common barriers to resident RSA at your institution?

33. Small groups of 4-5 Five minutes to discuss, then we’ll bring back to larger group Identify stumbling block(s) – Where are you now? – Where do you want to be? – Receptive to change? – Departmental support?

34. Common themes Creative solutions

35. References Family Medicine RRC requirements accessed online 3/2/12 http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf Boyer EL Scholarship Reconsidered 1990 AAFP Recommended Curriculum Guidelines for Family Medicine Residents. AAFP reprint no. 280, 289C. Accessed online 3/8/12. http://www.aafp.org/online/en/home/aboutus/specialty/rpsolutions/edugui de.html http://www.aafp.org/online/en/home/aboutus/specialty/rpsolutions/edugui de.html DeHaven MJ, Wilson GR, O’Connor-Kettlestrings P. Creating a Research Culture: What We Can Learn From Residencies That Are Successful in Research. Fam Med 1998;30(7):501-7. http://www.fpin.orghttp://www.fpin.org Family Physicians Inquiries Network

36. Questions? Suggestions?