Do Training Programs Give Otolaryngology Residents the Necessary Tools to Do Productive Research?

With the 80-hour weekly cap on resident hours implemented in 2003, resident publications in peer-reviewed journals have increased substantially (Clin Orthop Relat Res. 2010;468:2278–2283). But are residents toughing it out on their own when it comes to conducting research, or do training programs now give them relevant instruction in doing productive research, and the confidence that comes with it?

A 2015 study of third-year psychiatric residents found that when given an interactive, web-enhanced course to provide the theoretical and methodological tools for conducting and reporting systematic reviews and meta-analyses, participants reported a statistically significant increase in their confidence to conduct systematic reviews and meta-analyses (J Grad Med Educ. 2015;7:445–450). During the 36-week course, these residents also saw a boost in their academic productivity, which included 11 conference presentations and four peer-reviewed published manuscripts, two of them award-winning.

Cristina Cabrera-Muffly, MD, an otolaryngologist and residency program director at the University of Colorado (CU) in Aurora, said otolaryngology residency programs are doing a good job of teaching research skills. “I’ve been a part of several programs, whether in training or being employed there, and all of these programs have given residents a good research background.”

Protected Research Time

The Accreditation Council for Graduate Medical Education (ACGME) currently requires a minimum of three months of protected time for otolaryngology residents to conduct research, though many programs give their residents more. ACGME also requires that programs provide instruction in research methods and design outcome assessments, and they recommend that the research experience culminate in a manuscript that is ready to be submitted for publication.

Research training, however, can vary from institution to institution, with some programs geared toward training otolaryngologists in private practice and others geared toward those who want to become academics or researchers. Dr. Cabrera-Muffly said some programs go through changes over the years that may include more of an emphasis on research.

Researchers of a 2017 study found that the otolaryngology residency programs they surveyed do value research, as evidenced by financial support provided and requirements beyond the ACGME minimum (Otolaryngol Head Neck Surg. 2017 Jun;156(6):1119-1123). Of the 98 allopathic otolaryngology training program directors surveyed anonymously online, 53% managed programs with a dedicated research coordinator, 58% ran programs with basic science lab space and financial resources for statistical work, 67% had residents with two to three active research projects at any given time, and 63% had resident research requirements beyond the ACGME mandate of preparing a “manuscript suitable for publication” prior to graduation.

At the CU School of Medicine, otolaryngology residents get four months of dedicated, protected research time. Before their four-month block begins, however, they are expected to find a topic and a research mentor, as well as gain Institutional Review Board approval. “What we try to do is get them set up so that they can hit the ground running when that four months starts,” said Dr. Cabrera-Muffly. During their protected time, CU medical school residents conduct experiments and collect data. Most draft their manuscripts after the protected block is finished.

Seven years ago, CU School of Medicine began its grant-supported T32 institutional training program for pre-doctoral and post-doctoral fellows with projects related to otolaryngology, including hearing/balance, taste/smell, communication, and head and neck cancer. These T32s, usually one per year, receive an additional two years of research training. They are assigned a basic science research mentor who supervises them in a laboratory environment and a clinical co-mentor who provides experiences such as participation in a clinical research study or shadowing in a clinical environment.

While programs dedicated to training private practice clinicians may become more academically oriented, those with T32s usually remain dedicated to training clinician scientists, said Dr. Cabrera-Muffly.

Some otolaryngology programs, like the Hospital of the University of Pennsylvania in Philadelphia, attract residents who are more academically oriented than others. “More than 70% of our residents enter fellowship training and more than half enter academic jobs,” said Michael J. Ruckenstein, MD, MSc, an otorhinolaryngologist and director of residency training and education at the hospital. “This is very different than the national mean, which is about 25%.”

We’re very fortunate to have basic research in all the domains of our specialty, and therefore we don’t like to push residents into any particular area but rather let them choose based on their own interests. —Michael J. Ruckenstein, MD, MSc

Exposure to Research Opportunities

Early in their first year of training, Penn exposes residents to a wide array of research opportunities, said Dr. Ruckenstein. “We want them, over the next year or two, to evaluate these different opportunities and see how they mix with their own interests,” he added. “We’re very fortunate to have basic research in all the domains of our specialty, and therefore we don’t like to push residents into any particular area but rather let them choose based on their own interests.”

Some residents at Penn start interacting with researchers during their second year and others during their third. They’re required to submit a research proposal to a research committee during their third year for approval of their research plan, which is a six-month period during their fourth year. While Penn has a number of residents who have already attained academic degrees in research, Dr. Ruckenstein said that some of them come in “fairly research naïve” and are “bitten by the bug.”

Dr. Ruckenstein believes that if residents aspire to emerge as independent researchers, they need to have undergone research training prior to residency or be able to supplement that training post residency. “I don’t think six months is sufficient to be an independent researcher, but rather a collaborator with-full time researchers,” he said.

Most programs are pretty transparent about how much they value research. —Cristina Cabrera-Muffly, MD

Using Med School Research as a Vehicle into Residency

As matching into otolaryngology has become increasingly competitive, medical students now use research as a way to distinguish themselves. A 2017 study coauthored by Dr. Cabrera-Muffly and published in the Laryngoscope found multiple factors associated with successfully matching into an otolaryngology residency—publications among them (Laryngoscope. 2017;127:1052–1057). Her research showed that, on multivariate analysis, indicators of academic achievement such as awards and publications, as well as Alpha Omega Alpha Honor Medical Society status, were significantly associated with the odds of matching into otolaryngology.

The study also found that the criteria that grant a medical student admission to an otolaryngology residency are not necessarily correlated with resident success in that program. “We urge selection committees to begin identifying applicant selection methods that reflect the values we want to cultivate in our future colleagues,” the study said.

If a residency program values publications during residency, however, a 2017 Canadian study found that residents who publish at least one paper before residency are nearly six times as likely to publish during residency than those who did not publish before residency (J Otolaryngol Head Neck Surg. 2017;46:34).

Stacey T. Gray, MD, program director of the Harvard Otolaryngology Residency Program and director of the Sinus Center at Massachusetts Eye and Ear in Boston, sees a fair amount of medical students coming into residency having already conducted research. And she is continually impressed by how many resident researchers she sees at national meetings and conferences. “You get the sense that it’s something that, I think because of the requirements for having a research rotation, is embedded in the majority of programs at this point.”

From an applicant standpoint, Dr. Cabrera-Muffly said she thinks most applicants can get a pretty good idea of how research heavy an institution is during their interview. “Most programs are pretty transparent about how much they value research,” she said.

Issues in Research

At Harvard, residents get five months of dedicated research time in two separate rotations: the first 10 weeks as a PGY-3 and the next 10 weeks as a PGY-4. And, as a PGY-2, residents at Harvard take a monthly evening lecture series called Issues in Research before picking their required focus research project, which is a longitudinal study. David Jung, MD, PhD, an otologist and neurotologist at Massachusetts Eye and Ear Infirmary who studies skull base disorders, teaches the series. He also brings in guest lecturers throughout the year who are experts in evidence-based research or patient-reported outcomes. Topics range from the ethics of research to how to choose a research question and what to consider before actually undertaking a study.

“One of the big things that Dr. Jung has instituted is that part of that year is understanding how to actually write a CORE Grant,” Dr. Gray said. The Centralized Otolaryngology Research Efforts (CORE) grants program is a collaboration of foundations, societies, and industry supporters that provide support for research in the field of otolaryngology–head and neck surgery.

Learning to Write CORE Grants

Residents at Harvard use the CORE Grant application as a template and, by the end of the Issues in Research course, every resident has written one of the grants. “Whether or not they actually will apply or not is separate,” Dr. Gray said. “But they have to go through the exercise of picking a project and actually thinking about it so that they actually do all the background reading.”

By the time they start their PGY-3 rotation in research, the residents are up and running and may have even completed their Institutional Review Board applications. Most of them do submit the grants, and while some are successful, Dr. Gray said that not getting funded can also be a valuable lesson in being realistic, even among highly successful people.

“The funding landscape is so difficult right now across the country,” Dr Gray said, adding that fewer than 10% of projects get funded.

Research Burnout

Dr. Ruckenstein said it has become apparent to him over many years of choosing and mentoring residents that it’s almost impossible to predict who will pursue an academic career. “I can give two examples of residents who came in with extraordinarily strong research training they continued to pursue and were successful in publishing during residency and would be on anybody’s short list, ” he said. “But prior to fellowship they decided to abandon research and academic aspirations and enter community practice.”

Alternately, he has seen residents come in with far less impressive academic credentials and become completely enamored of research, going on to make great discoveries in the field. “Bottom line is, it’s not the training, it’s the passion,” he said.

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Renée Bacher is a freelance medical writer based in Louisiana.