A qualitative study exploring graduated medical residents’ research experiences, barriers to publication and strategies to improve publication rates from medical residents

Abstract

Background

In Kenya, postgraduate medical residents must complete a research dissertation for their Master of Medicine studies. However, the subsequent publication rate is lower than in higher-income settings, limiting the availability of population-specific data. This study explored residents’ experiences with research, reasons for the low publication rate, and strategies to improve publication rates.

Methods

In-depth interviews were conducted with 9 faculty members and non-academic support staff, as well as 18 Master of Medicine graduates who had successfully completed their research projects, to investigate their experiences with conducting, supervising, and publishing research. The interview data was analysed using inductive thematic analysis. The study also explored strategies to improve publication rates.

Results

The graduates (former medical residents) described difficult research journeys – from concept development to final submission of dissertation – which discouraged them from seeking publication. Many faculty and staff lacked time or sufficient expertise to successfully guide residents to publication. Departmental research culture, faculty expertise as supervisors and prioritisation of clinical work over research and lack of dedicated research time impacted both residents’ and faculty capacity for research. Strategies to improve publication rates focused on developing faculty research expertise, more protected research time, and a more structured approach to teaching research methodology, including academic writing skills.

Conclusions

Residents in low- and middle-income countries such as Kenya encounter systemic and personal challenges to successful publication of research. The ease or difficulty of a resident’s research journey influences their attitudes to subsequent publication. Strategies to improve publication rates can improve the dissemination of relevant research data in such settings.

Background

A dissertation is an original research study that meets the scientific, professional, and ethical standards of its discipline and advances a body of knowledge. Published dissertations contribute to the peer-reviewed scientific literature [1]. The main goals of academic scholarship are to generate and disseminate new knowledge and to contribute to the existing body of scientific evidence on which best clinical practice is based. It aims to produce scholars who will continue to contribute to the development of empirical, population specific data [1, 2]. Published research increases institutional prestige and visibility for grant-giving agencies and for highly talented faculty [3, 4].

Globally, the publication rate of dissertations by postgraduate medical residents ranges from 7 to 66%, with an average of 40% [2, 5, 6]. In high-income countries, the rate is in the higher end of this range − 45–66%, compared to low- and middle-income countries, where it averages between 7% and 30% [7, 8]. Some factors that contribute to this difference include inadequate training in research for residents, fewer local journals to publish in, scarcity of resources – financial, information access – and publication bias [9, 10]. Failure to publish research findings blocks the scientific community from accessing locally generated data, thwarts evidence-based practice and wastes academic resources. This denies local populations the potential benefits of data that is relevant to them. In addition, according to the Helsinki declaration, failure to share research findings is an injustice to the participants from whom the data was collected [11].

At Aga Khan University in Nairobi (AKU, N), postgraduate Master of Medicine students are required to complete a research dissertation as part of their curriculum. The Commission for University Education of Kenya also mandates that Master’s students publish at least one article in a peer-reviewed journal before they can graduate [12]. However, at the time of this study, publication was not a mandatory graduation requirement for these postgraduates.

AKU, N offers multiple supportive mechanisms for student research and publications. From a longitudinal course in research methodology, which is mandatory for all postgraduates, to departmental research committees which help vet research at concept stage and a Research Support Unit that avails methodological, statistical and analytical expertise. Further, publication fees are either waived or are paid by the University. Despite these institutional efforts to facilitate residents’ research and encourage them to publish, the conversion of dissertations to publications is relatively low. An unpublished 2020 retrospective audit of publication rates at (AKU, N showed that only 30% (67/224) of alumni had published their dissertations. AKU, N therefore made a good setting for the investigation of why, despite supportive institutional mechanisms, the publication rate is low.

Aim

We conducted this study to explore Master of Medicine graduates’, their faculty supervisors’ and non-academic and research support unit staff’s experiences of conducting, supervising and supporting research. We sought to discern the reasons for the relatively low conversion rate of completed research projects into journal publications and to identify local strategies to improve the publication rate of graduates’ research.

Methods

This exploratory qualitative study was conducted at the Medical College, Aga Khan University, Nairobi. There are nine postgraduate medical programs in the Medical College, with 130  medical residents and over 135 faculty and 40 non-academic support staff, including about 12 research support unit staff. To date, the programs have over 300  alumni. The aim of the study was to determine graduates’ experiences of conducting research and publishing, considering the relatively low conversion of dissertations to publications. Most of the study respondents were the alumni of the medical college who had graduated from the residency programs between 2008 and 2020. Graduates, supervising faculty and other non-academic and research support unit staff from the Medical College were chosen as the ideal sample because they had either completed dissertations as part of their curriculum or been involved in supervision and support of the process, making them well-suited to explore challenges and factors influencing research completion and publication.

Ethical approval to conduct this study was obtained from the AKU institutional ethics research committee and from the Kenya National Commission for Science Technology and Innovation (NACOSTI). Purposive sampling was used to select a representative sample from a population of 290 graduates, 145 faculty, and 40 support staff, to obtain participants representative of all nine specialties, both genders and various ranks of faculty and research and non-academic support staff. Each potential participant was approached individually after identification. A study information flyer outlining the purpose of the study was provided to potential participants, followed by a detailed verbal explanation. Afterward, informed consent was obtained, and an interview date and time were scheduled. If a participant declined or showed no interest, another suitable participant was selected purposively. A structured questionnaire was used to capture participants’ socio-demographic characteristics at the start of the interview. A semi structured interview guide was used to gather respondents’ views. In-depth interviews were conducted with 18 graduates, two faculty members, two program directors, a university librarian, a senior administrator, a member of the institutional ethics review committee and two research support staff between January and April 2021. The interviews were recorded and later transcribed. Interviews were conducted and recorded until thematic saturation was achieved.

Strict data protection measures ensured study participants’ confidentiality. Sensitive personal data were removed from the data set and identification numbers were assigned to interview transcripts which were accessible only by the research team. Inductive thematic analysis of the transcribed interview data followed. NVivo ^® software was used to create codes from all transcripts. Two researchers individually collated these codes into themes by identifying common patterns that linked them. Subsequently, the final themes were jointly reviewed by the two researchers (the principal researcher and a qualitative data analyst) and discussed until thematic consensus was reached.

Results

Of the faculty and staff members, 6 (67%) were male while 3 (33%) were female. 3 (33%) had over 10-year tenure, 5 (56%) over 5 years and 1 (11%) below 5 years.  4 (44%) were clinical faculty members and 5 (56%) were non-academic and research support staff.

Nine (50%) of the graduates were male and nine (50%) were female. Of the 18 graduate respondents, 5 (28%) had published successfully and were academically affiliated in their current role whereas only 2 (11%) with publications did not have an academic affiliation.

The socio-demographic data of the study participants is presented below (Table 1 and 2).

Table 1.

Gender, designation and tenure of faculty and support staff

Respondent	Gender	Designation	Tenure at AKU (years)
1	M	Faculty (research supervisor)	> 10
2	M	Research Support Unit member	> 5
3	F	Research Support Unit member	> 5
4	M	Ethics Committee Member	> 10
5	M	Program Director	> 5
6	M	Administrative staff, Medical College	> 5
7	F	Faculty (research supervisor)	> 5
8	F	Program Director	< 5
9	M	University librarian	> 10

Table 2.

Sociodemographic data, research experience, publication and academic affiliation of graduates

No:	Gender	Yrs. since graduation	Has current academic affiliation?	Prior research experience?	Successful publication of dissertation?
1	M	5–9	Y	Y	Y
2	F	5–9	Y	N	N
3	F	> 10	Y	Y	Y
4	M	1–4	N	N	N
5	M	> 10	Y	N	N
6	M	5–9	Y	N	Y
7	F	5–9	N	N	N
8	F	> 10	Y	N	N
9	F	1–4	N	N	N
10	F	1–4	N	N	N
11	M	1–4	N	Y	Y
12	F	1–4	N	N	Y
13	M	> 10	Y	Y	Y
14	F	5–9	N	N	N
15	M	5–9	N	N	N
16	M	> 10	Y	Y	Y
17	M	1–4	N	N	N
18	F	5–9	N	N	N

Key M = Male F = Female Y = Yes N = No

Four themes emerged from the data; graduates’ attitudes to research publication were informed by the ease or difficulty of their research journeys, the departmental culture affected both residents and faculty’s research output and lack of time and research expertise alongside a culture of prioritization of clinical duties over research hindered research activity.

Graduates’ challenging experiences with conducting and publishing research

Most graduates described difficult research journeys, which discouraged them from publishing their dissertations. The process of topic selection, proposal development, seeking ethics approval and completing their dissertations on time, sometimes without adequate faculty support was stressful and off-putting to many. To compound these difficulties, many of them had had minimal prior exposure to research during undergraduate training.

‘You struggle to come up with a [research] question probably with very minimal input from your program director or from your senior faculty. Then even getting people to support you to develop that idea is challenging’(R6).

As a result, many respondents described themselves as having a generally negative attitude towards research, not seeing it as particularly valuable, especially when considering their immediate career paths after graduation.

‘Why am I being forced to do this after my studies? After my Masters, I am done, I’m never going to publish and I’m never going to teach, I just want to treat patients’ (R6).

‘…. people really do not see the point of even having a dissertation in the first place’ (R16).

Faculty and program directors who were interviewed agreed with this assessment.

‘They [residents] look at research as that really difficult problem, or that thing you have to do to make sure you graduate but if you had a choice, you wouldn’t do it’(F2).

'They say is that the worst part about a post graduate program is the dissertation’ (F3).

Departmental research culture matters

The departmental culture also impacted both residents’ and faculty attitudes to research. More research-oriented departments stimulated stronger interest in it and, consequently, more resident publications. Additionally, faculty from more research-oriented departments were more willing to supervise and oversee residents’ publications before and after graduation. Thus, residents who trained in departments that had a positive research culture benefited immensely, enjoyed and embraced the research process and were mentored to publish their dissertations.

‘There are departments that publish more frequently than others and maybe this could be accountable to the fact that they have Chairs who are more attuned to research part of the academic track than those other departments where Chairs or Programme Directors or supervisors are more focused on clinical work. This percolates down to the residents, and it is infectious in the sense that it influences how everyone in the department perceives certain things including research’ (F6).

Conversely, in departments with weaker research cultures, residents struggled. Faculty with little or no experience and training in research were reluctant to participate in research or supervise and mentor residents. This engendered in residents a lack of interest in research and publishing.

‘It wasn’t really something in the department maybe that’s why I also didn’t take it up more seriously or give it more priority’(R2).

Many of the departments do not have support from faculty who have exposure to research. It’s only a few of them who have that exposure so sometimes it’s a bit challenging for somebody where the student plus the faculty are groping in the dark when it comes to matters research (R1).

Prioritisation of clinical work over research

Both residents and faculty reported a culture of prioritization of clinical duties over research. This resulted in a conflict of priorities, with clinical work winning out in most instances.

‘…. I don’t think the system was very conducive for that [research]. Because they tend to prioritize your clinical duties as opposed to research’ (R2).

‘……You can make it here as a very good clinician without being able to do research’ (F2).

Publication challenges despite institutional support mechanisms

Both faculty and residents acknowledged the institution’s effort and facilitation in various ways to create an enabling environment for research and publications. These included weekly departmental journal clubs, regular faculty academic rounds, facilitation to attend local and international research workshops/conferences and research funding. Research training through a robust curriculum was particularly helpful for residents without prior research exposure. Other resources included an online and physical library, access to various online databases, and the establishment of a research support unit.

‘The fact that we have a research department and statisticians and all that, to me that is good support from the institution and having dedicated faculty’ (R14).

‘The curriculum was supportive enough to enable me to know what to write, which format and what to put where’ (R9).

Despite this institutional support, and even when some of the above challenges were overcome, residents who were keen to publish still encountered challenges with the process of journal selection, the editorial process of converting their dissertations to a manuscript, meeting the stringent journal requirements and dealing with rejection from journals. Interestingly, article processing charges were not a barrier to publishing, given the institution’s funding support for those willing to publish.

Of the eighteen graduate respondents, five had published successfully and were academically affiliated in their current role whereas only two with publications did not have an academic affiliation. The rest had not published and were not in academically affiliated positions. Only two of the respondents without prior research experience had managed to publish successfully.

Strategies to improve the publication rate of residents’ research

Strategies suggested by the respondents for improving the publication rate include support in early identification of a viable research topic by residents. As faculty were sometimes too inexperienced in research to guide topic selection, both faculty and residents recommended faculty development and engagement in research methodology, process and supervision skills.

‘…. at least one of the faculty should be funded to maybe undertake an MSc in epidemiology’ (R18).

‘Ensure that faculty are also engaged in research. Not just the residents’ research but their own research as well such that they get exposed because you cannot supervise a resident to do research yet you yourself don’t do any research’ (F2).

Respondents suggested some curriculum changes that would improve residents’ experience of research and publication. Importantly, a curriculum revised to give more protected time for residents to carry out their research. They suggested that some of the teaching and support for residents should be offered online, to enable them to engage with material asynchronously. This would allow them flexibility in learning, which could mitigate the problem of clinical versus academic time management. Another desirable curriculum change for residents was the introduction of an academic writing skills course.

Surprisingly, making the publication of residents’ research a mandatory requirement for publication was a popular recommendation from both faculty and residents.

‘One of the requirements is that by the time you want to sit for your final exam you must have sent a manuscript to a journal’ (F1).

Finally, the introduction of an institutional journal to disseminate their work was suggested. This was recommended, despite the existence of an institutional research repository (AKU Commons).

‘The institution should go through the whole process and start an institutional journal…. that becomes your stepping ground into publishing before you start looking for the big ones’ (F1).

Discussion

This study identified four key obstacles that residents face in conducting and publishing research: lack of time, inadequate research skills and mentorship, challenging research processes, and departmental research culture. These impediments to publication are remarkably similar in comparable lower income settings. Studies of resident research in other LMIC settings reveal comparably low rates of publication. Adebayo’s Nigerian study in 2022 showed a publication rate of only 33%, with their residents facing similar hurdles. Obuku’s systematic review revealed a publication rate of postgraduate students’ research in LMICs of 7%, with a citation rate of 17% [8, 13]. Even when publication rates were higher in higher income settings, the obstacles remained the same: lack of time, lack of adequate faculty support or mentorship, insufficient research skills training and poor academic writing skills [2, 9, 13–18].

Although many residents undertake research simply to fulfil curricular requirements, there are those who do it out of interest, wanting to develop research expertise for future career advancement prospects and to publish their work [3, 17]. The ease or difficulty of a resident’s research journey informs their attitude to subsequent publication. Residents with little or no prior research experience who face challenges do not enjoy their research journey and are less likely to publish [17]. Preparing a manuscript, submitting it, and responding to reviewers’ feedback is time-consuming and requires expert mentorship. Graduated residents often lack the time, motivation, or mentorship to complete the publication process [2, 19]. Departmental research culture plays a key role in scholarship success. A culture that supports research promotes residents’ interest in it [20]. Having a robust departmental research program, with tenured research positions for faculty and a body of ongoing research projects allows residents and faculty to collaborate on ongoing research ; this can ease the pain of generating new topics for research. It is unsurprising that faculty with more than 10 years’ tenure have significantly more publications than those with less than 10 years [20]. Experienced faculty mentorship of residents’ work pays dividends – graduated residents in this study who had identified experienced mentors were better able to navigate the research process than those who had not. In lower income settings, research mentorship could work at an institutional or multi-site collaboration level: experienced or tenured researchers in other institutions could provide guidance [1].

Additionally, a positive research culture supports faculty development and participation in research, enhancing their skills and experience [21]. Because inadequate research mentorship is a key barrier to graduates’ successful scholarship [15], faculty development efforts should include both methodological and supervisor skills training, as well as grant and funding expertise [1].

For residents, early exposure to research and research mentorship from more experienced colleagues during the resident’s journey could be effective. Early exposure to research could begin at the undergraduate level – in this study those with prior exposure were more successful at publishing. Out of many interventions to increase student scholarship, the introduction of early research training for trainees was the most impactful, while the formal allocation of a research mentor was deemed a ‘failed intervention’ [15]. Effective research mentorship should ideally be a natural, organic mentoring relationship rather than formally assigned and ideally should continue after graduation, as graduate research is typically published two to three years after graduation [15, 22, 23]. It should facilitate early identification of viable research topics, avoid flawed methodology and wasted effort.

The constraint of time for research during postgraduate residency training, as seen in this study, is a common issue elsewhere, with the age-old conflict between clinical and academic time for both residents and faculty being an important impediment to publication. As in other settings, residents and faculty prioritized their clinical duties and patient care over research [16, 24]. The faculty payment model at the study site is fee-for-service: the majority of a physician’s earnings are on a per-patient basis [4, 25]. Thus, faculty physicians’ salaries are pegged to the amount of clinical work they perform and only a minority of faculty members have more than 5–10% of their time and earnings dedicated to research, and actively carry out their own research. Residents therefore experience that the broad emphasis for the faculty is on delivering clinical service and attending to patients, rather than on research [4].

The core missions of academic medical centres like AKU, N are centred on clinical service, education and research [4]. Novel and sustainable approaches to financial and material support and research partnerships are required to deliver research and education without compromising clinical service delivery. Such approaches should be context and institution specific.

Deliberate allocation of paid, protected time for research, away from patient care and teaching, such as in tenured faculty or grant-supported research positions would mitigate both the clinical imperative for remuneration and the lack of dedicated research time [4, 25]. However, this approach suggests a mutual exclusivity of research and clinical work which may not be accurate. An alternative strategy would be to broaden the scope of clinically based projects that represent Master’s level research. For example, well-structured, rigorous clinical quality improvement projects, clinical case series or health services research including outcomes and cost effectiveness of clinical interventions [26]. These are clinically focused and can generate publishable data. Other ways of managing the lack of time for research include investment in the infrastructure to deliver a blended asynchronous research curriculum for busy residents. Allocating more protected time for residents’ research, per se, may not yield the expected positive dividends for residents’ publications: residency programs with dedicated research time did not produce significantly more, or higher quality peer reviewed publications than those without dedicated research time [27].

This study highlights key subtleties when thinking about institutional and research capacity, especially in low- and middle-income settings. It particularly focuses on the availability of financial and material resources weighed against less easily quantifiable obstacles, such as research expertise, mentorship, and departmental culture.

However, it is limited by being conducted in a single setting with a relatively small sample size, which may not reflect the broader situation and reduces the generalisability of the findings. Respondents who graduated more than five years ago had to rely on recall and may have under/over-estimated the impact of some factors. Some of the graduates interviewed are current members of faculty and could therefore present mixed perspectives.

Conclusion

An original research dissertation is a curriculum requirement for most postgraduate medical students. Publishing this research contributes to global medical knowledge and increases representation from lower-income settings in scientific literature. However, many dissertations in these settings remain unpublished, despite residents’ desire to share their work. Systemic and personal challenges, such as inadequate mentorship and lack of time, hinder the conversion of dissertations into publications, even though academic centres make efforts to promote scholarship.

The evidence from this study suggests that improving publication rates requires strategies that improve the culture of research, the mentorship of residents and the skills of supervising faculty. Academic medical centres should cultivate a positive research culture. Enhancing faculty development to provide better research mentorship, along with early exposure and training in research skills, are key steps suggested herein. Additionally, broadening the remit of Masters level research to include more types of clinical academic enquiry and enabling collaboration across disciplines and institutions can also boost research output.

The importance of research in low- and middle-income countries (LMICs) should not be underestimated. Ensuring the publication of residents’ work is crucial so that valuable research doesn’t remain confined to library shelves (Fig 1).

Fig. 1.

Summary of recommendations

Authors’ reflection

It is interesting to reflect on the paradox that resident doctors are key end-users of evidence-based medicine and are keenly aware of the importance of population-relevant data yet their contribution to the body of literature remains scanty. In settings such as Kenya, there is an imperative need for relevant data, yet the very people who could be at the forefront of such data generation are hindered by the same factors that crop up in higher resource settings. Innovative approaches to addressing the issue of low rates of publication of graduates’ dissertations need not always be rooted in spending more money.

Abbreviations

AKU

Aga Khan University

AKU, N

Aga Khan University, Nairobi

CUE

Commission of University Education (Kenya)

LMIC

Low- and middle-income country

LMICs

Low- and middle-income countries

NACOSTI

National Commission for Science Technology and Innovation (Kenya)

Author contributions

B.M. contributed to the conception, design, collection of data, analysis and write-up of the research project and this manuscript. D.K contributed to the conception, design and write-up of the research project and this manuscript. W.S. contributed to the conception, design and write-up of the research project and this manuscript. C.K contributed to the conception, design, data analysis and write-up of the research project. All authors read and approved the revised final manuscript.

Funding

Funding for the research was provided by the Aga Khan University.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Aga Khan University Research and Ethics Committee (Ref: 2020/IERC-92 (v1)). Informed consent was granted by all the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.