BJ Hillman

BW Beasley

EC Leira

EH Schein

KR Riggs

L Penrose

M Abramson

M Higgs

R Herbert

WW Souba

Research, education and patient care are important missions of academic health centres and their respective teaching programmes. Yet, teaching hospitals struggle with ways to effectively support quality research initiatives. These issues are even more pronounced in countries with developing medical education systems where inconsistencies in training programme structure and quality, along with the lack of uniformity in the backgrounds and experience of the faculty, can hinder meaningful research activities. Hospital leaders recognized the need to inculcate both the desire and the ability to conduct quality research into every postgraduate training programme. Given the lack of global benchmarks, the institution developed and implemented the FIRST Programme (Focus on International Research Strategy and Teaching), a hospital-wide approach to research strategy training and support in 2010–2012. Over a 3-year period, the number of resident and faculty research activities has more than doubled. The types of research studies have also changed over the past few years, with an increase in basic science and randomized clinical trials. Our experience with implementing an institution-wide research initiative has been quite encouraging. Through leadership commitment, the institution has witnessed substantial increases in both trainee and faculty scholarship over a 3-year period.</jats:p

Halah Ibrahim

Satish Chandrasekhar Nair

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S H O W A N D T E L LFocus on international research strategy and teaching:the FIRST programmeHalah Ibrahim • Satish Chandrasekhar NairPublished online: 5 December 2013 The Author(s) 2013. This article is published with open access at Springerlink.comAbstractResearch, education and patient care are important missions of academic healthcentres and their respective teaching programmes. Yet, teaching hospitals strugglewith ways to effectively support quality research initiatives. These issues are evenmore pronounced in countries with developing medical education systems whereinconsistencies in training programme structure and quality, along with the lack ofuniformity in the backgrounds and experience of the faculty, can hinder meaningfulresearch activities. Hospital leaders recognized the need to inculcate both the desireand the ability to conduct quality research into every postgraduate trainingprogramme. Given the lack of global benchmarks, the institution developed andimplemented the FIRST Programme (Focus on International Research Strategy andTeaching), a hospital-wide approach to research strategy training and support in2010–2012. Over a 3-year period, the number of resident and faculty researchactivities has more than doubled. The types of research studies have also changedover the past few years, with an increase in basic science and randomized clinicaltrials. Our experience with implementing an institution-wide research initiative hasbeen quite encouraging. Through leadership commitment, the institution haswitnessed substantial increases in both trainee and faculty scholarship over a3-year period.Keywords Research strategy  Research teaching  International medical education Graduate medical educationH. Ibrahim (&)  S. C. NairAcademic Affairs Department, Tawam Hospital, PO Box 15258, Al Ain, Abu Dhabi, United ArabEmiratesemail: hibrahi4@jhu.edu123Perspect Med Educ (2014) 3:129–135DOI 10.1007/s40037-013-0098-4BackgroundResearch, education and patient care are important missions of academic healthcentres and their respective teaching programmes. Studies have shown that residentparticipation in research is correlated with an increased number of lifetimepublications [1], encourages future careers as academics [2], increasessubspeciality fellowship training opportunities [3], and can ultimately lead toimproved patient care [4]. Despite the importance of resident scholarship, graduatemedical education has historically focused on clinical service and education, withpatchy and inadequate attention to research training [5]. In recognition of theimportance of incorporating research into residency training, regulatory bodiesworldwide, including the Arab Board for Medical Subspecialities, the United Statesbased Accreditation Council for Graduate Medical Education and the UnitedKingdom’s Royal College of General Practitioners require scholarly activity for bothtrainees and faculty. Strategies for improving research productivity have includedrecruiting a post-doctoral researcher to coordinate and support resident projects [6];implementing a multimodal educational intervention to provide training in researchand statistics [7]; and developing a formal, structured research rotation [8]. Theseapproaches, almost exclusively at the individual programme level, have had varyingdegrees of success, and training programmes in all disciplines continue to strugglewith ways to provide effective research experiences [9]. These issues are even morepronounced in countries with developing medical education systems whereinconsistencies in training programme structure and quality, along with the lack ofuniformity in the backgrounds and experience of the faculty, can hinder meaningfulresearch activities.The United Arab Emirates (UAE) is a small nation bordering the Persian Gulf.Over the past two decades, the country has become a political and economic leader inthe Arab World and is a rapidly developing region for medical education andbiomedical research [10]. The opening of the first medical school in 1984 paved theway for the development of residency training programmes in the mid-1990s.Subsequently, small-scale, independent research initiatives developed in someresidencies. However, research strategy was never formally introduced into thecurriculum for postgraduate medical programmes. Without central oversight,inconsistencies developed in the quality and effectiveness of research training inthe individual programmes and began to increase over time.Medical education leaders in our institution recognized the need to inculcate boththe desire and the ability to conduct quality research into every residencyprogramme. Given the lack of global benchmarks, the institution developed andimplemented a hospital-wide approach to research strategy training and support, theFIRST Programme (Focus on International Research Strategy and Teaching), in2010–2012 using established principles of change management. We hope thatlessons learned from our experience will provide a foundation for research strategyand teaching in similar international teaching hospitals.130 H. Ibrahim, S. C. Nair123Setting and change modelTawam Hospital is a Joint Commission International-accredited 467-bed tertiarycare centre in Abu Dhabi in the UAE. Tawam sponsors nine residency and fellowshipprogrammes and serves as a training site for medical, nursing, and clinicalpharmacology students from various institutions of higher education. The institutionreceived ACGME-International accreditation in 2012.To bring about significant and enduring changes in the institution’s approach toresearch training, educational leaders turned to classic theories of organizationaldevelopment and change management [11, 12]. The basic tenets include creatingcompelling reasons to change (unfreeze); implementing the necessary changes(move); and developing systems for sustainability (refreeze) [12].Programme developmentPrior to 2010, few residents and faculty at Tawam Hospital were involved inresearch. Review of 2008 and 2009 submissions to the Institutional Review Board(IRB) did not reveal any resident collaborators. Peer-reviewed publications wereinfrequent for faculty and consisted mainly of case reports. Graduate surveysrevealed that only 47.1 % of graduating residents considered themselves competentto evaluate clinical evidence and even fewer (35.3 %) felt comfortable conductingclinical research. The most commonly identified barriers included lack of time due tocompeting pressures of patient care and education, lack of knowledge of basicresearch methodology and statistics, and unavailability of knowledgeable mentors.UnfreezeA major component of FIRST is communication between hospital administration andfaculty. The pursuit of excellence in research was added to the institution’s medicaleducation vision statement, thereby, highlighting the importance of research as a corecomponent of medical training. Faculty development sessions, which previouslyfocused on teaching and evaluation skills, included workshops on basic statistics andresearch methodology. The Director of Clinical Research, a PhD with significantexperience in conducting clinical trials, took a lead role in implementing theinstitution’s strategy for research training. Hospital-wide Continuing MedicalEducation (CME) lectures were conducted to create awareness. Topics includeddescriptions of the basic types of research, introduction to the IRB, and formulating ascientific hypothesis.Move (transition)Barriers to conducting effective research were addressed during this stage. Theinstitution’s main objectives were to: (1) provide research methodology training, (2)allocate protected time for scholarly activity, and (3) identify and train mentors.International research strategy and teaching 131123(1) Research methodology training The Research Director conducted a series ofworkshops on research methodology. The timing of the lectures concurred withresident protected academic time, leading to an over 80 % attendance rate.Topics included opportunities and challenges for clinical trials, researchmethodology, and research ethics. In addition to the hospital-wide sessions,workshops were scheduled with the individual training programmes, coveringtopics such as study designs, basic statistical concepts, and critical appraisal ofthe medical literature. Journal Club sessions were started in all the trainingprogrammes to provide the trainees with an opportunity to utilize theinformation acquired during the workshops.(2) Allocating protected time for scholarly activity The commitment to researchwas further demonstrated in the individual training programmes by allocating2–4 week formal research blocks annually. Ongoing projects were continuedduring all 3–5 years of residency. The curriculum of the research block variedby discipline, but objectives included identifying a faculty mentor, designing aresearch study, performing a literature review and submitting an application tothe local IRB. In most programmes, research rotations replaced electives so asnot to disrupt clinical services.(3) Identifying and training mentors A 3-day workshop on research methodology,conducted by external experts, was offered to all programme directors and coreteaching faculty. All workshop participants agreed to serve as faculty mentorsfor resident research projects. On-going guidance and support was provided bythe Research Director.RefreezeTo ensure that the commitment to support and mentor scholarly activity was upheldby the faculty, evaluation of their contribution to medical education was included aspart of their annual performance appraisals. For trainees, participation in scholarlyactivity became an important component of evaluations and promotions. Residentabstract and poster presentations at national conferences were openly recognized andfinancial support was provided for travel. To further encourage research productivity,the number of peer-reviewed publications was introduced as a key performanceindicator (KPI) for all Abu Dhabi teaching hospitals in 2010.OutcomeOver a 3-year period (2010–2012), sessions dedicated to assisting residents withactivities, such as idea generation and research design, increased by 733 %,including an increase in workshops focusing on methodology (345 %) and researchethics (183 %). A sevenfold increase from 2 resident projects in 2010 to 14 in 2012was observed for research studies registered at the hospital’s central clinical researchdatabase and approved by the IRB. The institution also noted a transformation fromlimited basic science research conducted by the faculty prior to 2010 to translational132 H. Ibrahim, S. C. Nair123studies after 2010, with many involving resident collaborators. There was a steadyincrease in retrospective chart reviews to assess incidence and prevalence,behavioural studies to assess quality of life, observational studies, such as diseaseregistries, and phase II, III and IV clinical trials (Fig. 1). Phase 1 clinical trials are notpermitted by the regulatory authorities in the UAE.DiscussionThere are numerous obstacles to faculty and trainee involvement in research,including lack of protected time, inadequate mentorship opportunities andinsufficient knowledge of research strategies. In addition to these challenges,international training programmes often lack the infrastructure and support toeffectively encourage resident scholarly activity. Our experience with implementingan institution-wide research initiative has been quite encouraging. Throughleadership commitment and the development of systems to embed (or refreeze)the new attitudes and behaviours into organizational culture, the hospital haswitnessed substantial increases in both trainee and faculty scholarship over a 3-yearperiod.Fig. 1 Number of research studies approved by IRBInternational research strategy and teaching 133123The current state of scholarly activity in our institution appears to be robust.However, funding, curricular changes, protected time and mentors are all necessaryto support resident scholarship, and it is unclear how much effort must be expendedto maintain this degree of research productivity, or if the manpower and financialresources have been diverted from other critical components of postgraduatetraining. Long-term sustainability of the programme and generalizability to otheremerging health care systems will require better strategies for funding and innovativeways to improve education without escalating costs. Institutional collaborations andsharing of local resources and expertise are essential. International collaborationsthrough teleconferencing of workshops and e-mentoring can also provide supportwith minimal increased costs. Through the support of academic and executiveleadership, the FIRST Programme can be effectively implemented at otherinternational teaching hospitals.Essentials• Resident participation in meaningful research activity benefits the individualtrainee and the hospital as a whole.• Training programmes worldwide face barriers in supporting resident researchproductivity, including constraints in time, research methodology training andmentorship opportunities.• An institution-wide approach to research teaching, if supported by hospitalleadership, can successfully improve trainee and faculty research productivity.Conflict of interest The authors report no declarations of interest.Ethical approval Ethical approval was obtained from the Al Ain Medical District Human ResearchEthics Committee.Open Access This article is distributed under the terms of the Creative Commons Attribution Licensewhich permits any use, distribution, and reproduction in any medium, provided the original author(s) andthe source are credited.References1. Riggs KR, Reitman Z, Mielenz T, Goodman P. Relationship between time of first publication andsubsequent publication success among non-PhD physician-scientists. J Grad Med Educ.2012;4(2):196–201.2. Hillman BJ, Fajardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti JV. Factors influencingradiologists to choose research careers. Invest Radiol. 1989;24:842–8.3. Souba WW, Tanabe KK, Gadd MA, Smith BL, Bushman MS. Attitudes and opinions toward surgicalresearch. A survey of surgical residents and their chairpersons. Ann Surg. 1996;223:377–83.4. Abramson M. Improving resident education: what does resident research really have to offer? TransAm Acad Ophthalmol Otolaryngol. 1977;84:984–5.5. Herbert R, Levine R, Smith C, Wright S. A systematic review of resident research curricula. AcadMed. 2003;78(1):61–8.134 H. Ibrahim, S. C. Nair1236. Penrose L, Yeomans E, Praderio C, Prien S. An incremental approach to improving scholarly activity.J Grad Med Educ. 2012;4(4):496–9.7. Leira EC, Granner MA, Torner JC, Callison RC, Adams HP. Education research: the challenge ofincorporating formal research methodology training in a neurology residency. Neurology.2008;70:e79–84.8. Kanna B, Deng C, Erickson S, Valerio J, Dimitrov V, Soni A. The research rotation: competency-based structured and novel approach to research training of internal medicine residents. BMC MedEduc. 2006;6:52. http://www.biomedcentral.com/1472-6920/6/52.9. Beasley BW, Scrase DR, Schultz HJ. Determining the predictors of internal medicine residencyaccreditation: what they do (not what they say). Acad Med. 2002;77:238–46.10. Nair SC, Ibrahim H, Celentano DD. Clinical trials in the Middle East and North Africa (MENA)Region: grandstanding or Grandeur? Contemp Clin Trials. 2013;36(2):704–10.11. Higgs M. How can we make sense of leadership in the 21st century? Leadersh Organ Dev J.2003;24(5):273–84.12. Schein EH. Kurt Lewin’s change theory in the field and in the classroom: notes towards a model ofmanagement learning. Syst Pract. 1996;9(1):27–47.International research strategy and teaching 135123

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Focus on international research strategy and teaching: the FIRST programme

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