Advancements in clinical orthopaedic treatment require a strong foundation in the basic and clinical sciences. The enormous funding activities of the U.S. National Institutes of Health underscore the importance of medical research—and the financial backing needed to support it—to the clinical practice of medicine. Despite this well-accepted notion that research is critical to medical progress, many questions regarding how to best support these research endeavors remain. One uncertainty involves the declining numbers of individuals who may be best equipped to bring discoveries in the laboratory to the bedside: the clinician-scientist (a physician who also performs research).
Although much has been written about the dearth of such a species of investigator1-13, little is known about the desires and incentives of the most obvious potential short-term and long-term source of these physicians—the resident in training1,14. In addition, surgical specialties in general and orthopaedics in particular have had difficulty recruiting and cultivating clinician-scientists, more so than other specialties in medicine15-26. So, the questions remain: Is there a realistic pool of residents from which to develop the orthopaedic clinician-scientist, and what incentives will help our field to achieve that goal?
In order to answer these questions, a survey of orthopaedic residents and residency chairs was performed with four goals: (1) to identify whether residents and chairs acknowledge the importance of orthopaedic research, (2) to determine the proportion of orthopaedic residents who express a baseline level of interest and intent to perform research, (3) to identify factors that may influence the residents’ intent to perform research, and (4) to contrast these factors with the opinions of department chairs who are most likely to have local influence over the research environment.
Participants and Recruitment
The study format was an institutional review board-approved cross-sectional opinion survey. From September 2005 until December 2006, residents from seventeen orthopaedic surgery residency training programs and the chairs of those programs, who were on a list obtained from the American Orthopaedic Association (AOA), were solicited for participation. Because we were unable to obtain a randomized sample from the total pool of allopathic orthopaedic residents at that time, we sought to contact program coordinators and directors with the goal of targeting approximately one-tenth of the total pool. We first assembled a list of programs that had more than one resident participating in the Clinician Scientist Development Program of the American Academy of Orthopaedic Surgeons or that received an Orthopaedic Research and Education Foundation (OREF) resident grant (in the previous three years). Twelve such programs were identified. We then randomly selected from a list of programs until we had obtained 10% of the total allopathic orthopaedic resident pool. Of the thirty-four programs contacted, sixteen supplied us with the e-mail addresses of residents. The included programs varied in size (from one to ten residents per year), location, and academic emphasis. Our home institution was included specifically to assess the reliability of the survey instrument by comparing responses obtained from the same pool of residents six months previously27. All study participants were asked up to six times by e-mail to participate in the study; those who did not respond were declared nonresponders. The survey instrument was administered online and consisted of twenty-four closed-ended questions for residents and fifteen questions for chairs (see Appendix) designed to assess the four goals previously outlined. The response rate was 44% (183) for the residents and 60% (eighty-six) for the chairs.
Statistical Analysis and Nonresponders
All responses were stored on a secure server, and analyses were performed anonymously through the use of unique identifiers. We used Student t tests and chi-square tests, as appropriate, to identify differences between clinicians who were or were not interested in research. We included all variables associated with research interest in univariate analyses at a level of p < 0.20 in a multivariate logistic regression model. Significance was defined as a p value of <0.05.
As a proxy assessment of the consistency of respondent answers, we compared the responses to the question about the "likelihood of pursuing research as part of your career" by the same residents at the University of Pennsylvania with their answers to the identical question posed six months earlier. Acknowledging that opinions could change in six months, the average response of the twenty-eight residents who responded to both surveys (among thirty-four who were eligible for both) was nearly identical at 2.60 and 2.64. Finally, we randomly selected fifty nonresponders by means of multiple e-mail solicitations to mitigate concern about nonresponder bias. Abbreviated questionnaires that collected data about demographic characteristics and intent to perform research were sent to these nonresponders; similar statistical analyses were performed on these data. Among the twenty-seven initial nonresponders for whom we subsequently obtained baseline characteristics, the age, stage in training, and debt were not significantly different from the data for the responders to our primary questionnaire. The percentage of residents who did not want to perform research as a part of their careers ("unlikely" or "definitely not") was similar between responders and nonresponders (30% and 26%, respectively; p > 0.5).
Importance of Research
To establish a rationale for increasing the number of orthopaedic clinician-scientists, we first sought to establish the perceived importance of research in the clinical practice of orthopaedics. Ninety-nine percent of the residents and chairs thought that research was important, and 99% of the residents and 98% of the chairs believed that orthopaedic surgeons should perform some of this research.
Desire to Perform Research
Residents were then asked to rate their own likelihood of performing research as part of their professional careers and to indicate what the topic of that research would be. Forty-two percent responded that they were likely or definitely going to perform research, whereas 28% were undecided and 30% were not interested (Fig. 1-A). The most desired type of research was clinical (65%), followed by biomechanics (11%) and basic science (9%) (Fig. 1-B). When asked to identify the ideal amount of professional time dedicated to research, 28% selected full time; 28%, two to four day-equivalents per week; and 44%, less than two days.
Resident Characteristics Associated with Research Interest
We examined a number of factors hypothesized to be associated with the level of interest in research. Of the factors analyzed (Table I), prior research experience, primary authorship of a manuscript, and older age (in years, not training level) were associated with higher interest (i.e., "likely" or "definitely") in the univariate analysis (p < 0.05). A multivariate logistic regression model, with use of the significant variables and debt, identified primary authorship of a manuscript as the only independent predictor of high interest (odds ratio = 1.56; 95% confidence interval, 1.15 to 2.09; p < 0.005). We also sought to identify a pool of residents who were unsure about research—a potentially recruitable group. Younger residents and women were more likely to be unsure about research according to univariate (p = 0.002 and 0.034, respectively) and logistic regression (p = 0.022 and 0.034, respectively) analyses.
Stimulating Interest
Residents were asked to rate a list of incentives that had a potential to increase their interest in research during residency (left column in Table II) and after residency (right column in Table II). The highest rated incentives during residency were increased protected time and funding, and the highest rated incentives after residency were forgiveness of total educational debt and a salary equivalent to that of full-time clinicians. Chairs were asked to rate the same list. Ninety percent of the chairs thought that a chair who is supportive of research would provide increased incentive (right column in Table II). When the chairs were asked to select the incentives they were most willing to support during and after residency, the only incentive chosen by more than half of them was protected research time. Interestingly, the opinions of residents and chairs showed little congruence in general, as ten of twelve incentives after residency and three of eight incentives during residency showed significantly different ratings.
Paying for Research
When asked if orthopaedic research should be subsidized, 92% of chairs and 93% of residents answered in the affirmative. However, when asked if they would help to support those subsidies, only 40% of residents and 70% of chairs said they would.
Outreach
A majority of residents (58%) were aware of initiatives and online resources provided by the American Academy of Orthopaedic Surgeons, OREF, AOA, and the United States Bone and Joint Decade to support the orthopaedic clinician-scientist. However, only 14% of respondents had actually utilized any of those resources.
Consistent with existing opinions of so-called experts on the importance of the clinician-scientist, the residents and chairs in this study both thought that research was important to the clinical practice of orthopaedics and that it should, at least in part, be conducted by orthopaedic surgeons. It is important to note the overwhelming support for this notion by both chairs and residents alike as the translation of these opinions to real life (i.e., residents going on to research-integrated careers) has been quite underwhelming. It will be important in the future to identify why these interests and intentions are not realized. We may then provide more directed means of increasing the number of practicing surgeons who perform research.
The potential pool is clearly available as the combination of those interested in research and not sure of their interest—the enticeable crowd—is almost 70%. It is notable, however, that only about a quarter of those interested would like to perform basic-science research. The so-called enticeable residents should be the focus of our encouragement if we are looking for the best return on investment. Our data further suggest that those with prior research experience, lower debt, and manuscript authorship are more inclined toward future research. This implies that, along with trying to recruit younger residents and female residents (who are more likely to be unsure about research), we should have residents become actively involved with tangible outcomes such as writing manuscripts.
When examining the potential incentives for research posed in the survey, residents were most interested in protected time and funding during residency and in salary support and debt forgiveness after residency. On the other hand, chairs favored protected time during and after residency. The most telling aspects of this rating of incentives were not the actual numbers, but two interesting trends: (1) chairs were more optimistic about the potential incentives to increase research, and (2) the difference in rating was significant with regard to thirteen of the twenty incentives. It is clear that focusing on only one set of incentives would leave a conflicted picture. The optimal set of incentives may indeed be found by combining the results from both groups: a combination of protected time, increased access to funding, salary support, and debt relief.
Having set the stage—research is important, and there are potential ways to target and encourage residents to incorporate it into their future careers—we then asked, "Would you help to pay for it?" Both residents and chairs thought that some kind of subsidization was needed. However, about a quarter of the chairs and more than half of the residents indicated they would not do so at the expense of their department or at personal expense, respectively. This exemplifies one of the major problems with supporting research in a clinical setting: the difficulty in securing the financial support of those not actively participating in research. It will be important for all members of a group (even those who are not actively engaged in clinical or basic-science research) to understand the priority and importance of investigation to their clinical and academic mission—that productivity and excellence in that domain, like others, can be rewarded and incentivized.
There are a number of limitations to our study. Because we were unable to obtain a pool of residents from which to draw a random sample, we opted to select a representative group by surveying programs with varied size, location, and academic inclinations. Our response rate was low among the residents but consistent with surveys of similar groups28,29. Although we did not find evidence of nonresponse bias by subsequently sampling initial nonresponders, we cannot rule out the possibility that such bias exists because the study was not specifically powered to detect differences between initial responders and nonresponders. The response rate was higher among the chairs, likely because they are a self-selected group that already supports research and other academic pursuits. Additionally, our reported response rate may be a conservative estimate because we were unable to verify or document an actual refusal to participate30. As a cross-sectional study, our method does not allow a measure of outcomes over time. However, it does allow inclusion of a greater number of subjects (for the same amount of resources) and abrogates the biasing effects of time. Finally, while the survey instrument has been previously used27 and developed following recommended procedures for item development and piloting31, the questions focused on opinions and self-report of intentions and not on objective measurements.
These limitations notwithstanding, this study provides a unique glimpse into the perspectives of orthopaedic residents and chairs on the importance and future of orthopaedic research. It indicates that chairs and residents philosophically support musculoskeletal research by orthopaedic surgeons and that salary support, debt relief, increased research funding, and protected time are the cornerstones of providing residents with incentives for future research. Furthermore, chairs are willing to support subsidies for research although there must be departmentwide support as those potentially being taxed may be resistant to such subsidies.
It is critical that orthopaedic leadership organizations as well as practitioners at the local level continue their efforts to encourage research in orthopaedics. Concerted initiatives that provide incentives to the appropriate groups have great potential to increase research by orthopaedic surgeons in the future.
Note: The authors thank David L. Glaser for thoughtful discussions, Jonathan Wanderer for technical expertise in developing and deploying the web-based survey, and the University of Pennsylvania School of Medicine for providing server hosting and support for the survey.