Abstract
BACKGROUND:
Evaluating the research productivity of cardiothoracic (CT) surgery residents during their training and early career is crucial for tracking their academic development. To this end, the training pathway of residents and the characteristics of their program in relation to their productivity was evaluated.
METHODS:
Alumni lists from integrated 6-year thoracic surgery (I-6) and traditional thoracic surgery residency programs were collected. A Python script was utilized to search PubMed for publications and the iCite database for citations from each trainee. Publications over a 20-year time span were stratified by the year of publication in relation to the trainee’s graduation from thoracic surgery residency. Trainees were analyzed by training program type, institutional availability of a cardiothoracic T32 training grant, and protected academic development time.
RESULTS:
A total of 741 CT graduates (I-6: 70, Traditional: 671) spanning 1971–2021 from 57 programs published over 23,000 manuscripts. I-6 trainees published significantly more manuscripts during medical school and residency compared to traditional trainees. Trainees at institutions with CT T32 training grants published significantly more manuscripts than those at non-T32 institutions (13 vs. 9; p = 0.0048). I-6 trainees publish more manuscripts at programs with dedicated academic development time compared to trainees at programs without protected time (22 vs. 9; p = 0.004).
CONCLUSIONS:
I-6 trainees publish significantly more manuscripts during medical school and residency compared to their traditional colleagues. Trainees at institutions with T32 training grants and dedicated academic development time publish a higher number of manuscripts than trainees without those opportunities.
Research is important for advancement of cardiothoracic surgery. The publishing of research via peer-reviewed manuscripts is used to evaluate trainees for admission into medical school, residency, appointment to a faculty position, evaluation for promotion or tenure, and extramural funding.(1–8) Therefore, evaluating research productivity through publications for cardiothoracic surgery trainees is of utmost importance.
Academically-inclined general surgery programs have found ways to fund protected time for residents to either perform research or pursue graduate degrees (MPH, MBA, MSc, or PhD). (2, 9, 10) The competitive nature of Integrated Thoracic Surgery Residency “I-6” programs has previously been evaluated, and a strong publication record is important for admission into these programs. (8, 11, 12) I-6 thoracic surgery residency programs have the option of incorporating protected academic time for trainees. A dedicated analysis evaluating the publication record of trainees prior to entering residency and the impact of protected time for these residents has not been performed. Furthermore, the academic productivity and publication record of traditional 2/3-year trainees has not been evaluated compared to residents graduating from newly established I-6 programs.
To this end, publication records of cardiothoracic surgery trainees 10 years prior to and following cardiothoracic surgery residency graduation were evaluated with the hypothesis that training paradigm affects academic productivity of residents. Residents were evaluated based on training paradigm, specifically whether they trained in an I-6 surgery residency or a traditional 2/3-year thoracic surgery fellowship. The impact of training at an institution with a dedicated National Institutes of Health (NIH) cardiothoracic surgery T32 training grant or at an institution with protected academic development/research time was analyzed. Finally, contribution of trainees to the manuscripts they published were evaluated, particularly whether trainees were first author or a senior author on manuscripts.
MATERIAL AND METHODS
Collection of Resident Data
Using the Accreditation Council for Graduate Medical Education’s (ACGME) publicly available list of accredited programs for both “Thoracic surgery – Integrated” and “Thoracic surgery”, we compiled a list of programs for both I-6 and traditional 2/3 year Thoracic surgery fellowships (Traditional) (Figure 1, Supplemental Table 1).(13) Each residency program’s website was queried for a list of alumni including graduation year. Resident graduation years spanned from 1971–2021. Middle initials and middle names were collected if available to aid in PubMed queries (described below). Residents and fellows who had not yet graduated from their training program at the time of residency were excluded. The total number of manuscripts published in the lifetime of graduates was collected. These data were further filtered for the following timespan: 10 years prior to CT training graduation and 10 years following CT training graduation for a total of 21 years. Use of this timespan is denoted appropriately. Finally, the private or academic nature of the trainee’s first job after CT training was collected. The collection of resident names was performed by one author and checked by another author. We identified residents by middle initial, topic of study, and location of affiliation on the manuscript. Papers from residents who changed their name after marriage were excluded; however, this was a minority of trainees based on manual evaluation.
Figure 1.
CONSORT Style Diagram of Data Collection and Analysis. A total of 75 traditional 2/3 year thoracic residency programs and 34 Integrated “I-6” programs were queried with 42 traditional programs and 15 I-6 programs having publicly available alumni lists. Our query included 672 traditional trainees and 72 I-6 trainees. Publications records 10 years prior to and following thoracic surgery residency were evaluated.
Collection of Manuscripts
Lists of institutions, graduates, and MeSH terms were imported into a relational database model (RDM). Unique institution IDs and graduate IDs were automatically generated upon import. A Python script was written utilizing the following packages: pymed - for handling and parsing results from PubMed, pyodbc - for communicating with the local database engine, requests - for handling the web requests to PubMed.(14) An iterative approach was used to query the PubMed API for each graduate by full name and include 50 of most used MeSH terms in surgery articles developed from a broad search of trainees. Each article and author were stored in the RDM using the PubMed ID. Authorship sequence was also collected. The unique graduate ID was stored in a many-to-many relationship table within the RDM allowing multiple graduates to be linked with the same article. An initial list of around 34,000 articles were obtained from PubMed and stored. This list was exported, and hand reviewed to exclude articles from authors that may have had the same name from different fields of study, or journals unrelated to surgical medicine. Citations for each manuscript were collected by querying the NIH’s iCite database using the PubMed ID of each manuscript.(15) A validation of the methodological approach used in this study was conducted that involved comparing the automated manuscript collection with manual manuscript collection for 8 surgeons across a distribution of career stages. The automated approach identified approximately 80% of all published manuscripts relative to manual abstraction.
Chronological Analysis
Manuscripts associated to each trainee were assigned to the year in which they were published. Respective citations generated from manuscripts were assigned to the year in which the manuscript was published. Graduates were only included in analysis for a given year beyond graduation if data were available. For example, a trainee who graduated in 2020 (year 0) will have data for years −10 (2010) to +2 (2022). This example graduate will not have any data for year +3 (2023) and beyond.
Distribution Number of Manuscripts Published
The total number of publications from each surgeon was collected. Surgeons were grouped according to number of publications they published in bins of 10 (0–10, 11–20 etc). The binned groups were fit with a one-phase decay.
Statistical Analysis
GraphPad Prism version 9.2.0 for MacOS (GraphPad Software, San Diego, California) was utilized for all statistical analyses. Categorical variables were analyzed with a χ2 test, while the Student’s t-test or the Mann-Whitney U test were used for continuous variables. A non-parametric paired Wilcoxon matched-paired signed rank test was used to compare resident publication before and after residency graduation. An alpha value of 0.05 was used to determine significance.
Institutional Review Board
This study was exempted from review by the University of Michigan’s Institutional Review Board.
RESULTS
Study Cohort
A total of 75 Traditional thoracic surgery (2/3 year) training programs and 34 I-6 surgery (6 clinical years) residency programs were investigated. Of these programs, 42 traditional programs and 15 integrated programs had publicly available alumni lists, resulting in 671 traditional and 70 I-6 trainees. Publications by trainees were collected from PubMed (Figure 1).
Training paradigm analysis
Residents from Traditional programs were compared to their I-6 colleagues (Table 1). Traditional trainees published 21,492 manuscripts and I-6 trainees published 1,533 manuscripts. There was no difference in the median (IQR) number of publications of the surgeons (Traditional: 13 [4–36], I-6: 10 [7–21.75]; p = 0.6158). The median number of manuscripts published 10-years prior to and 10-years following thoracic surgery residency was evaluated. There were no differences in the median number of manuscripts published by traditional (10 [2–25]) or I-6 trainees (10 [5.25–20.25]) (p = 0.1738). When evaluating the temporal distribution of publications, we find that I-6 trainees publish significantly more manuscripts while in medical school (p < 0.02) and during the last 4 years of their residency (p < 0.05). Traditional trainees publish more manuscripts during years 6 and 8 after thoracic surgery training (p < 0.01) (Figure 2). A total of 23/30 (76.7%) I-6 trainees who publish at least 10 manuscripts during their residency go into academic practice compared to 43/70 (61.4%) of all I-6 trainees. A total of 116/156 (74.4%) traditional trainees who publish at least 10 manuscripts go into academic practice compared to 61.7% of all traditional trainees.
Table 1:
Training Program Evaluation
| Traditional | Integrated “I-6” | p-value | |
|---|---|---|---|
| Institutions | 42 | 15 | - |
| Residents | 671 | 70 | - |
| NIH Funding ($Million) 1 |
218.0 [130.2–402.0] | 153.5 [66.3–356.4] | 0.172 |
| Total Manuscripts | 21,472 | 1,533 | - |
| Median # Manuscripts 1 |
13 [4–36] | 10.5 [7–22.3] | 0.8360 |
| Manuscripts during time period 1, 2 | 1,3620 | 1,417 | - |
| Median # Manuscripts1 |
10 [2–25] | 10.5 [5.8–21.0] | 0.096 |
| Median Manuscripts per surgeon year1 | 0.476 [0.1 – 1.2] | 0.476 [0.3 – 1.0] | 0.096 |
Presented as median [Interquartile range], p-value calculated using Mann Whitney U Test for entire life-span of surgeon
Time period defined as 10 years prior to and 10 years following thoracic surgery residency graduation year
Figure 2.
Longitudinal Analysis of I-6 vs. Traditional Trainees. Publications per year per surgeon is plotted from 10 years prior to thoracic surgery residency graduation to 10 years following thoracic surgery residency graduation. The number of manuscripts published by each trainee in each year is averaged and plotted with standard deviation. Each phase of training noted on the x-axis is a rough estimate: “Medical School”, “CT Training”, CT residency graduation is year 0, and “Early Career” follows thereafter. The timeline depicted within this Figure are illustrative and meant to represent a trainee’s expected progression. A two-way ANOVA with multiple t-tests was used for statistical analysis. * denotes p < 0.05.
Distribution Number of Manuscripts Published
Figure 3 displays the distribution of published manuscripts over a 21-year span by trainee type. Each group was binned by 10 publications. Both groups have nearly identical R2 values (traditional: 0.9804, I-6: 0.9925). The τ of each fit was 10.83 (traditional) and 11.22 (I-6). The majority of trainees publish between 0 and 10 manuscripts in their career (traditional: 305, I-6: 38; p = 0.2318). Among residents graduating prior to 2020, residents who published significantly during training (>10 manuscripts) continued to do so after graduation (22.62 during training vs. 26.34 after training; p = 0.0764). Those who do not publish significantly during residency (<10 manuscripts), start to do so during their early career (2.48 during training vs. 9.70 after training; p < 0.0001).
Figure 3.
Distribution of Manuscripts Published by Surgeons. The number of manuscripts published by surgeons (I-6 and Traditional trainees) during their lifetime is binned by 10 manuscript increments and plotted. Traditional trainees are plotted on the left Y-axis and I-6 trainees are plotted on the right Y-axis. The number of manuscripts is plotted on the X-axis. Of note, 15 traditional surgeons have published more than 200 manuscripts and are not plotted.
Institutional Training Grants
T32 training grants are institutional training grants funded by the NIH.(16) Training grants are funded to institutions who display at high level of research infrastructure and success in training scientists. Three institutions in our study currently have or had a dedicated cardiothoracic surgery T32 grant for a large duration of trainee data (Washington University in St. Louis School of Medicine, Baylor College of Medicine, and University of Virginia School of Medicine). Three T32 institutions had 125 trainees and non-T32 institutions had 619 trainees. Evaluating 10 years prior to and following graduation, T32 trainees publish significantly more manuscripts compared to non-T32 trainees (13 [5–32] vs. 9 [2–23], p = 0.0043) (Figure 4A). When evaluating citations, T32 trainees have a higher number of citations compared to non-T32 trainees (255 [68–640] vs. 139.5 [24–578.3]; p = 0.0035) (Figure 4B).
Figure 4.
NIH T32 Training Grant Institutional Analysis. Trainees were grouped by whether their institution had an NIH Cardiothoracic Surgery T32. The median number of (A) manuscripts or (B) citations for each surgeon during the 21-year analysis period are plotted with corresponding interquartile ranges. (A) Median number of manuscripts for trainees: T32: 13 [5–32], Non-T32 9 [2–23], p = 0.0043). (B) Median number of citations for trainees: T32: 255 [68–640], Non-T32 139.5 [24–578.3]; p = 0.0035. Mann-Whitney U-tests were performed and p-values are noted.
Protected Academic Development Time
Controlling for program type and availability of information regarding programs, the effect of having protected academic development time in I-6 programs was evaluated. Residents at institutions with protected academic time (1–3 years) published a significantly higher number of manuscripts per trainee compared to trainees at institutions without protected academic time (22 [9–38] vs. 9 [5.5–17.5]; p = 0.004) (Figure 5A). Trainees with protected academic time also generated a higher median number of citations compared to their colleagues without protected time (379 [80.5–761.5] vs. 95 [57.5–224]; p = 0.0038) (Figure 5B). There is no difference in trainees going into an academic faculty position between the trainees who attended institutions with protected academic time (14/25) compared to trainees from institutions without protected academic time (29/45) (p = 0.487).
Figure 5.
I-6 Surgery Residency Protected Time. Trainees were grouped by whether their I-6 program provides protected academic development time for research or other academic pursuits. The median number of (A) manuscripts or (B) citations for each surgeon during the 21-year analysis period is plotted with interquartile range. (A) Median number of manuscripts for trainees: Protected time: 22 [9–38], no protected time: 9 [5.5–17.5], p = 0.004). (B) Median number of citations for trainees: Protected time: 379 [80.5–761.5], no protected time: 95 [57.5–224]; p = 0.0038. Mann-Whitney U-tests were performed and p-values are noted.
Authorship Position
First or senior authors of manuscripts are considered the biggest contributors to a manuscript. Therefore, we analyzed the authorship position of trainees on manuscripts they published. A total of 21,492 traditional trainee manuscripts and 1,533 I-6 manuscripts were analyzed (Table 2). Over their lifetime, traditional trainees have published more first author manuscripts compared to their I-6 colleagues (12 [4–6] vs. 4 [1–7]; p < 0.0001). However, we then accounted for the career longevity of traditional trainees compared to the relatively shorter careers of I-6 trainees due to the recent establishment of I-6 training programs. Factoring in relatively shorter careers for I-6 trainees thus far, we find that I-6 trainees have published a higher percentage of first author manuscripts compared to their traditionally trained colleagues (30.6% [12.5 – 46.4] vs. 20.0% [3.7 – 38.1]; p = 0.0029).
Table 2:
Authorship Position
| Traditional | Integrated “I-6” | p-value | |
|---|---|---|---|
| Total Manuscripts | 21,472 | 1,533 | - |
| First author manuscripts1 | 3 [1–9] | 4 [1–7.3] | 0.188 |
| % of all manuscripts1 | 20.0% [3.6 – 38.1] | 30.6% [12.5 – 47.1] | 0.001 |
| Last author manuscripts1 | 0 [0 – 3] | 0 [0 – 1] | 0.001 |
| % of all manuscripts1 | 0 [0 – 13.0%] | 0 [0 – 4.2%] | 0.0004 |
| Other authorship position | 4 [1 – 15] | 5 [1 – 8] | 0.668 |
| % of all manuscripts | 36.2% [20.2 – 53.3] | 36.4% [19.6 – 53.4] | 0.923 |
Presented as median [Interquartile range], p-value calculated using Mann Whitney U Test
COMMENT
I-6 trainees publish significantly more manuscripts during medical school and CT training compared to traditional trainees. I-6 graduates from programs with protected academic development time publish more manuscripts compared to I-6 graduates from programs without protected time. Trainees from institutions with dedicated cardiothoracic surgery T32 grants publish more manuscripts compared to non-T32 trainees.
I-6 Trainees Publish More in Medical School and Residency
I-6 residents publish significantly more manuscripts during medical school and residency compared to traditional trainees. There are no differences in the number of publications or citations between traditional trainees or I-6 trainees during their career span. However, I-6 trainees publish significantly more manuscripts during medical school and towards the end of their cardiothoracic surgery training (Figure 2). Matching into an I-6 program is difficult, with impressive average scores on USMLE Step 1 (247.5) and USMLE Step 2 (255.1).(17) Pursuing CT surgery may drive medical students to dedicate more time to research and demonstrate early academic productivity, a potential predictor of academic success.(18) One potential reason for the increase in publications for I-6 trainees in the last 4 years of CT residency is that 43 of 70 trainees are currently in academic positions and may have focused on developing a strong academic portfolio. Publication records during medical school were included in our analysis to highlight the early initiation of academic productivity among I-6 residents; this proclivity carries forward and once again becomes significantly different compared to traditional trainees as residents prepare to embark on lifelong academic pursuits after residency training.
Despite early success in medical school and during CT residency, I-6 trainees do not publish as many manuscripts compared to their traditional colleagues after residency. One possible contribution is that 4/13 (30.8%) of I-6 graduates in year +6 after graduation are in academia, compared to 267/458 traditional graduates (58.3%) (p = 0.0477). In year +8 after graduation, only 1/4 (25%) I-6 graduates are in academia compared to 218/381 (57.2%; p = 0.196). Surgeons in private practice likely perform less research and are not publishing as many manuscripts compared to their academic colleagues.
Cardiothoracic Surgery T32 Institution Trainees Have Higher Academic Productivity
Previous work has shown that general surgery residents benefit from cardiothoracic surgery T32 grants.(2) These residents go on to obtain more NIH funding and hold more leadership positions.(2) Here, we find that cardiothoracic surgeons who receive their CT surgery training at institutions with a dedicated cardiothoracic T32 grant (T32 n = 125 vs non-T32 n = 616) publish significantly more manuscripts (13 vs. 9; p = 0.0048; Figure 4A) and their papers have significantly more citations (255 vs. 139.5; p = 0.0035; Figure 4B). This data reiterates the importance of a structured research training paradigm that is afforded to institutions by NIH training grants. Institutions that are focused on the development of future academic CT surgeons and CT surgeon-scientists, should aim to have a dedicated CT surgery T32 to provide trainees with financial support and mentored research opportunities.
NIH Funding and Research Years
There are no differences in NIH funding at institutions that have I-6 programs or traditional programs for the fiscal year 2021 (Table 1).(19) Therefore, the differences we see in increased productivity of I-6 residents during CT residency is not due to the fact that these trainees had better infrastructure and NIH-funded opportunities. While the NIH funding of the institution is not the only important component in determining research productivity, it does drive basic science research.(3, 4, 20–22) The future of cardiothoracic surgery is bright, with increasing NIH funding and the recognition that surgeon-scientists contribute to advances in research.(9, 23) However, in order to continue producing surgeon-scientists, institutions must invest in infrastructure for surgical research.(1, 21)
Our evaluation of I-6 residents at institutions with protected research time compared to institutions without this opportunity demonstrates that academic productivity of residents is increased by having dedicated research years (Figure 5). Institutions geared towards producing academic surgeons should provide trainees with funded, dedicated research time with no clinical requirements. This funding could come from internal departmental funding or extramural federal funding obtained by the department. Affording residents this opportunity will require institutional leadership to hire surgeon-scientists and basic science researchers, and provide research funding, lab space, and protected research time for faculty surgeon-scientists to run research laboratories. Currently, 14 I-6 Surgery residencies are true 6-year programs without required or structured research time. Trainees interested in pursuing an academic career may opt to pursue residency at an institution offering 2 years of protected research time to build a research foundation for their junior faculty years.
Limitations
We were limited in our study by the availability of publicly posted alumni lists from training program websites. We have captured approximately half of the institutions in each training paradigm. Further, we have attempted to capture as many manuscripts from there trainees as possible with a combination of MeSH terms related to surgery and manual analysis by the authors. While the timespan of traditional trainees ranged from 1971–2021, 602 (89.8%) graduated after 2000 and in the same training era as I-6 graduates abrogating our concern regarding time bias in publication patterns. We were not able to capture if someone was a co-first author; only the name listed first on the author list was considered to be the first author. Upon random sampling we found that greater than 80% of manuscripts were captured. Next, while the majority of schools have listed the graduation year and training type (I-6 versus traditional 2/3-year programs), we searched LinkedIn, Doximity, and their current professional page to obtain residency graduation year if it was missing.(24, 25) Finally, our study design does not permit us to comment on the clinical practice and volume of the surgeons, as we only evaluated the academic productivity of surgeons.
Conclusions
Cardiothoracic surgery trainees are very academically productive with no major difference between traditional or integrated training paradigms. However, I-6 trainees publish significantly more manuscripts during medical school and during residency. Institutions with a dedicated cardiothoracic surgery T32 training grant produce academically prolific surgeon-scientists, regardless of thoracic surgery training paradigm. The NIH receives a great return on investment when funding T32 grants and should fund more of them to support cardiothoracic surgeon-scientist research. When evaluating only I-6 trainees, graduates from institutions with protected academic development time publish significantly more. For trainees aiming to pursue a career in academia where publication record is scrutinized, in addition to the rigor of clinical training, the institutional availability of a dedicated T32 training grant and protected academic development time should be considered.
Supplementary Material
Acknowledgments:
We thank Matthew P. Hough for assistance with editing the manuscript.
FUNDING:
AKN funded by T32GM007267.
Adishesh Narahari reports financial support was provided by National Institutes of Health. Outside of this work, Dr. Likosky: (1) received research funding from the Agency for Healthcare Research and Quality and the National Institutes of Health; (2) served as a consultant for the American Society of Extracorporeal Technology; and (3) received partial salary support from Blue Cross Blue Shield of Michigan to advance quality in Michigan in conjunction with the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. The opinions, beliefs, and viewpoints expressed by authors do not necessarily reflect those of AHRQ, NIH or the U.S. Department of Health and Human Services, BCBSM, or its employees. Dr. Pagani is noncompensated ad-hoc scientific advisor for FineHeart, Medtronic, Abbott, and Abiomed, a member of the Data Safety Monitoring Board for Carmat and National Heart, Lung and Blood Institute PumpKIN Study, and serving as the chair of the Society of Thoracic Surgeons Intermacs Task. Dr. Ailawadi is a consultant for the following companies: Edwards Lifesciences, Medtronic, Abbott, CryoLife, Atricure, Anteris, Johnson & Johnson, and Phillips. Dr. Ailawadi is on the DSMB for Avania and has equity in Trifle, Anteris and Cardiomech
Footnotes
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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