26
OPINION
GENERAL SURGERY NEWS / JULY 2022
Publish or Perish: An Aphorism for General Surgery Residents BY MIGUEL A. LOPEZVIEGO, MD, FACS
I
t has now become a requirement for graduation from many of the five-year general surgery residency programs in this country for residents to complete an additional one or two years of compulsory basic science research. The medical students who hope to enroll in these programs are well aware of this obligation before they rank these programs on their match list, and therefore are obliged to fulfill this academic requirement at some point during their training. The vast majority of these medical students agree to this condition when selecting their desired surgical training programs despite having absolutely no idea what their eventual research project(s) will be. Subsequently, many of these medical students, as junior residents—after dedicating two or three years to their clinical training—come to the realization that they have absolutely no interest in, or passion for, basic science research. They then are forced to either lobby for an exception to this research requirement by filling a void
general surgery residency programs are so committed to the idea of mandatory research. In deliberations on subjects like mandatory resident research, it is prudent to investigate the question of who benefits from putting a resident in the lab. In America, that usually involves following the money! The term “publish or perish,” coined by Archibald Coolidge in 1932, helps open that discussion. All academic departments associated with universities are under intense pressure every year to provide evidence of research projects that lead to publications in peer-reviewed journals. It is the hope of every academic department that these research projects, if well received and impactful enough, will lead to lucrative grants. Nonetheless, even if funds are not generated to support the department, a lengthy bibliography of journal articles, regardless of their significance or quality, creates the impression for those who subsequently review the program, and its faculty, that a robust and inquisitive academic environment exists. These publications help the respective deans, department chairs and section chief to satisfy these academic expectations for “schol-
‘Perhaps it is time to consider the question of what value comes to our individual residents, and more importantly to our profession, when we force them into the laboratory to perform research they do not want to do.’
that has developed in the programs roster or reluctantly submit to this demand of their program director. Perhaps it is time to consider the question of what value comes to our individual residents, and more importantly to our profession, when we force them into the laboratory to perform research they do not want to do. Mandatory basic science research for general surgery residents is a controversial topic. For decades, many of the nation’s top academic residency programs have included dedicated time “in the lab” as a critical part of their residency training. Many of us may remember a time when Duke University’s surgery program was described as being “a decade with Dave (Sabiston).” However, there is little logic, and even less data, supporting the idea that mandatory research produces a better general surgeon. More importantly, it would be hard to argue that a 30-year-old resident who plans to go into community practice and will never again be involved in any type of research would not serve his patients better by doing two years of additional subspecialty fellowship training (in any subspecialty) instead of participating in some esoteric laboratory investigations that they care nothing about. As such, it seems we should now be asking why some
arly activities” while simultaneously buffing their own CVs (curriculum vitaes). Logically, so long as no dramatic additional financial costs are incurred, allocating a block of residents each year to mandatory laboratory work is likely to secure a guaranteed and reliable annual source of journal publications. When one recognizes the practical benefits of mandating resident research in the nation’s surgery departments, where the full-time academic faculty members’ careers and promotions are dependent on their quantity of publications, it is logical that we, as the surgeons charged with mentoring and training these residents, ask two very important questions: What benefit is society receiving from this type of research and what benefit is the individual resident obtaining from this significant time commitment? We should explore these questions separately. There was a time when most scientists, and nearly all educated people, believed that all research was good. This intuitively seems to be a logical point of view since one would hope that any new or incremental advances in knowledge or fine-tuning of past hypotheses and investigations should be beneficial to science, and thus to humanity. Interestingly, however,
any contemporary scholarly review of this issue will be met with hundreds of opinion pieces and research papers convincingly arguing that meaningless, poorly prepared, uninspired, and often fraudulent or misleading research studies are being prepared by poorly trained or incompetent researchers at a furious pace to fill the pages of the exploding number of print and online journals in order to satisfy the academic demands of our institutions of higher learning. Many of these journals will now publish, often for a hefty price, any scientific article you are willing to email to them. These publications confuse and dilute the priceless effect of the precious few high-value, rigorously performed studies, which should be guiding our practice of medicine. Many of these same meritless publications are blended later with the few credible ones to generate grand statistical meta-analyses of the compiled data, which can further confuse the clinicians who look for legitimate scientific guidance. The cost of these studies to taxpayers is not insignificant: Funding a resident’s salary and benefits for two years in addition to paying for the exceptionally high cost of operating a basic science lab just to “get their name on a few papers” that are then published in obscure journals and never cited again cannot be a clever way to use taxpayer dollars. Our fellow citizens would be shocked to see what a weak bang for the buck they are getting for funding mandatory general surgery resident research. We must at some point, as surgeons involved in resident education, ask questions such as: What was the last resident research project resulting from one or two years of full-time laboratory work by a resident in your institution (or at an away institution) that ended up impressing you or making a meaningful contribution to the science of surgery? Year after year, our residents disappear into the labs of this country and work hard to generate “a few papers” that bear their names as co-authors. Is this having any measurable benefit in the training of our surgeons or is this simply a nefarious route for academic surgery departments to generate more lines on their annual publication list? I would be fascinated to see what percentage of faculty members in our country’s surgery residencies have any idea what their own residents’ research projects and publications were during their mysterious two-year sabbaticals! The institutions of higher education in surgery have now stepped up the ransom on our residents even further. Many competitive fellowship programs, such as surgical oncology and pediatric surgery, all but demand two years of laboratory work. Why? Is this a high-level filter to lighten the number of residents applying for these highly prized fellowships, by weeding out the ones unwilling to submit to two more years of wasted time before they begin their practices? Is it not possible for a highly motivated and extraordinarily talented, clinically focused general surgery resident to complete an elite pediatric surgery fellowship and have a remarkable career in clinical surgery that benefits thousands of children? Our experiences suggest the answer is yes but that perhaps the machine of academic surgery with its thick bureaucracy, proud new divisions and complete lack of respect for a resident’s time (other than the 80-hour workweek rule) needs a constant captive labor force to help pound out the publications and keep the illusion of “the surgery research lab” alive. Let me be clear that I enthusiastically support allowing any motivated resident or medical student who
