The Intersection of Research and Surgical Training

Research and development (R&D) is the cornerstone of advances made in any field of human endeavour. It is those corporations and enterprises that devote a significant portion of their resources to R&D that continue to thrive and improve upon their profitability. Similarly, societies that encourage R&D will continue to enjoy a technological edge. So it is, also, with the science and art of Medicine. Health research has been the linchpin for advances in medical practice since the onset of the Galenic era and particularly in the last two centuries. Since the barber-surgeons of mediaeval Europe transformed into modern day surgeons, as exemplified by the royal charter granted to the Royal College of Surgeons in London in 1800, the culture of scientific research has been inculcated by practitioners. In this day and hour, ‘evidence-based medicine’ (sometimes called ‘evidence based health care) has been adopted by practitioners all over the world. This involves the use of current best evidence in making decisions about the care of individual patients. Such evidence can only be produced from sound scientific research.

Just as training is essential to gaining proficiency rapidly in surgical practice, competency in the conduct of health-related research also requires training. How to situate research training in the context of professional surgical training remains a subject of controversy, as the opinion expressed in the article ‘Thesis/dissertation as a part of surgery fellowship examination: is this necessary?’, published in this issue of the journal illustrates. Many believe that colleges that train and certify candidates as specialists in the various surgical disciplines should focus solely on the acquisition professional surgical skills and leave research training to the universities. The trend of opinion and practice in many parts of the world however seems to favour the integration of research training into the surgical residency training 1,2,3,4,5.

Surgical training is a multifaceted process that should produce not only a good clinician and technician, but also a good communicator, scholar, health advocate and a professional 1. Ability to conduct research and to critically appraise the output of research are needed skills for scholarship and advocacy, two important attributes of a surgeon as stated above. A surgical trainee or specialist should be able to read journal articles and draw the appropriate inferences that would influence his/her practice positively from such an exercise 6. Appreciation of what goes into the research process would enable the surgeon appraise the research output more proficiently. Many surgeons would also have roles as clinical teachers, often in universities. This would require that they have undergone research training in order to thrive in an academic environment. Thus, however it is acquired, research training is mandatory for the contemporary surgeon.

Most surgical training programmes now encourage periods of research activity as part of surgical training 1, and many have formalized this by requiring that candidates for the award of Fellowship in their colleges should prepare and defend a research dissertation in the candidate’s area of specialization 3,4,5. Prior to commencing data collection, the Fellowship candidate submits a proper proposal stating the objectives of the study and the hypotheses to be tested, after a review of the literature. Having obtained approval to proceed with the study, data is collected, followed by analysis and final preparation of the dissertation. The candidate is examined on such a dissertation as part of the overall assessment process before he/she is certified as a fellow of the college

In the Royal Australasian College of Surgeons, which introduced a thesis requirement in some surgical disciplines in 2008, trainees are not required to take time out from their clinical work to write the thesis. Although a pass in the thesis examination is mandatory, it forms only part of the final examination of the candidate which still lays an emphasis on clinical acumen and judgement 4. In India, where the submission of a dissertation has been a requirement for surgical residency trainees for more than sixty years 2, a clinical examination to test the ability of trainees to recognize signs and symptoms, their communication skills and bedside manners (as mandated by the Medical Council of India) is still the most important part of the fellowship examination. Subspecialty certification in the United States is provided by the various specialty boards and many of the surgical specialties, including Obstetrics & Gynaecology, require all clinical fellows to spend some time in research training. This must lead to the publication of an article in a peer-review journal before the candidate can be presented for examination and board certification. In many instances, the specialty boards require that fellowship trainees devote a full year exclusively to research as part of their fellowship training. In Uganda, many of the surgical trainees have actually called for a strengthening of the supervision process of the dissertation aspect of their residency training because of an appreciation of the value it adds to their training as surgeons 3.

It is therefore obvious that the integration of research training into surgical residency programmes is not unique to any part of the world and it is a trend that is expanding and one that many surgical trainees consider as desirable. That this approach has been adopted by the West African College of Surgeons is recognition of the fact that the modern surgeon is not only expected to be able to critically appraise research, but to contribute to the body of evidence upon which practice is based by conducting meaningful research. This does not imply that the Fellowship examination should be based solely on examining a thesis. There is no professional college anywhere that does this. Examination of professional acumen – requisite cognitive knowledge, skills and best practices - will continue to remain the most important portion of the exit examination before the Fellowship is awarded.

Integration of research into surgical training should also not be regarded as an attempt to equate professional fellowship certification with university doctorate degrees. They are two different types of qualifications with disparate underlying philosophies. The doctorate degree, in particular, is usually awarded by a university to someone who has conducted in-depth research in a specified field and has contributed something new to knowledge in that discipline. It certifies that the candidate has been trained in the techniques and rigour of research and can embark on a meaningful academic career. In other words, a doctorate degree is good preparation for a successful academic (research) career. Training of surgeons, on the other hand, focuses on the acquisition of professional knowledge, skills, and best practices although many colleges of surgeons now incorporate research training into the professional training curriculum. This means that graduates of such programmes can also embark on research careers even as they pursue careers in the practice of the surgical disciplines.

The emphasis should be on the competencies that graduates of each of these two approaches (doctorate degrees or fellowships) have, not the nomenclature of their certificates. While obtaining a doctorate degree may be excellent preparation, it is NOT the only way to prepare for a successful academic career. There are many accomplished academics and researchers, including Nobel Laureates, who never pursued or obtained a PhD. On the other hand, there are many PhD holders who could not make it to the grade of full professor, the acme of university acknowledgement of one’s academic contributions, in spite of teaching in the university for decades! Obtaining research training along with clinical skills acquisition certainly prepares surgeons for the intellectual rigour required of clinical teachers in universities.

Recalling my own personal experience as a trainee for the Fellowship of the National Postgraduate Medical College of Nigeria, my dissertation took nearly two years of data collection, analysis and write-up to complete, under the supervision of three senior colleagues. Having successfully defended it, I was able to extract four distinct original research articles from the dissertation which were published in 4 reputable journals with editorial offices in the Netherlands, Kenya, the United States of America and Nigeria respectively 7,8,9,10. This was the foundation upon which I was able to build a dossier of research publications that enabled me to move up the university academic ladder. This is to illustrate the fact that integrating research training into the Fellowship programme can assist in launching surgical specialists into successful academic careers.

The message therefore should be that the next generation of leaders in surgical practice should have research training integrated into their professional specialty training not out of a desire to turn the fellowship qualification into a research degree. Rather it is because the modern surgeon, apart from being an astute clinician and dexterous technician, must be fully competent in conducting scientific research to produce evidence for practice. The surgeon must also be proficient in critically appraising such evidence as produced by others in order to apply it to patient care in his/her practice.

References

1. Javed MS, Harrison E, Taylor I. The role of research in surgical training. Bulletin of The Royal College of Surgeons of England, 2003, 85 [4]: 120-123.
2. Gupta Anubhav, Kumar Surender, Kumar Shailendra, Mishra MC, Kumar Sandeep. Surgical residency programme: training, teaching and evaluation in general surgery – a peer opinion poll in five medical colleges in Northern India. Indian Journal of Sugery, 2006, 68 [6]: 310-315.
3. Galukande M, Luboga S, Kijjambu SC. Improving recruitment of surgical trainees and training of surgeons in Uganda. East and Central African Journal of Surgery 2006, 11 [1]: 17-24.
4. Royal Australasian College of Surgeons. Thesis requirements for cardiothoracic surgery. http://www.surgeons.org/surgical-specialties/cardiothoracic/thesis/. Accessed 22-11-2012
5. Orthopaedic Surgery Training Programme at the University of Pretoria and Patient Care at Steve Biko Academic Hospital. http://web.up.ac.za/default.asp?ipkCategoryID=18265&subid=18265. Accessed 22-11-2012
6. Spillane AJ, Crowe PJ. The role of the journal club in surgical training. Australian and New Zealand Journal of Surgery, 1998, 68 [4]: 288–291.
7. Omigbodun AO. Choice of intravenous fluid infusion in labour and maternal postpartum blood pressure. Tropical and Geographical Medicine, 1989,41: 227-229.
8. Omigbodun AO, Fajimi JL, Adeleye JA. Effects of using either saline or glucose as a vehicle for infusion in labour. East African Medical Journal, 1991, 68: 88-92.
9. Omigbodun AO, Akindele JA, Osotimehin BO, Fatinikun T, Fajimi JL, Adeleye JA. Effects of saline and glucose infusions of oxytocin on neonatal bilirubin levels. International Journal of Gynecology and Obstettrics, 1993, 40: 235-239.
10. Akinyinka OO, Omigbodun AO, Akanmu TI, Osanyintuyi VO, Sodeinde O. Hyponatraemia, birthweight and neonatal jaundice. African Journal of Medicine and the Medical Sciences, 1995, 24: 55-57.

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