An African Perspective on Publication of Postgraduate Residents’ Dissertation: A qualitative study exploring residents’ research experiences, barriers to publication and strategies to improve publication rates from Kenyan medical residents

doi:10.21203/rs.3.rs-4329376/v1

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An African Perspective on Publication of Postgraduate Residents’ Dissertation: A qualitative study exploring residents’ research experiences, barriers to publication and strategies to improve publication rates from Kenyan medical residents

https://doi.org/10.21203/rs.3.rs-4329376/v1

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published 04 Oct, 2024

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Background: Postgraduate medical residents in Kenya must complete and submit a research dissertation as part of their Master of Medicine studies. However, the rate of subsequent publication of this research is lower than the publication rate in higher income settings, denying Kenyans the potential benefit of population-specific data. This study was carried out to explore residents’ research experiences and reasons for the low publication rate and to identify strategies to improve the publication rate of residents’ research in low-income settings.

Methods: In-depth interviews of 8 faculty and academic staff and 18 former residents were conducted to investigate their experiences of conducting, supervising and publishing research. Strategies to improve to improve publications rates were explored.

Results: The former 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 attitudes to 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 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.

Medical Education

Low-Middle Income Countries

Postgraduate

Resident Research

Research publication

Kenya

LMIC Research.

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 rate of publication of dissertations by medical residents in training ranges between 7% and 66%, averaging 40% [2, 5, 6]. This rate is higher (45 to 66%) in high income compared with low middle income countries, which average 7 to 30% [7, 8]. Some factors that contribute to this difference include inadequate training in research for residents, a dearth of 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 the Aga Khan University, Nairobi, the post graduate Master of Medicine curricula require students to complete a research dissertation project, but publication is not a mandatory requirement to graduate. Despite the institutional efforts to facilitate residents’ research and encourage them to publish, the conversion of dissertations to publications is relatively low. A 2020 retrospective audit of publication rates at Aga Khan University, Nairobi (AKU, N) showed that only 30% (67/224) of alumni had published their dissertations.

Aim

We conducted this study to explore residents’ experiences of research, the reasons for the relatively low conversion rate and to identify local strategies to improve the publication rate of residents’ research.

This exploratory qualitative study was conducted at the Medical College, Aga Khan University, Nairobi. There are nine postgraduate programs, with 155 medical residents and over 200 faculty and staff. To date, the programs have over 350 alumni. The aim of the study was to determine graduated residents’ experiences of conducting research and publishing, in light of the relatively low conversion of dissertations to publications. The study respondents were the alumni of the medical college who had graduated from the residency programs between 2008 and 2020.

In-depth interviews with key informants – 18 graduates, two faculty members, two program directors, one university librarian and three members of the research support unit were conducted between January and April 2021. Purposive and quota sampling was used to select a representative sample of participants from a study population of 290 graduates, 145 faculty and 40 staff. Respondents were selected based on their ability and willingness to give information relevant to this study and included staff members who have worked closely with residents as they develop their dissertations and try to publish.

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).

An information flier outlining the purpose of the study was provided to potential participants, followed by a verbal explanation, after which informed consent was obtained and a date and time for the interview was agreed upon. A structured questionnaire was used to capture participants’ socio-demographic characteristics. A semi structured interview guide was used to gather respondents’ views. Interviews were conducted 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. NVivo® software was used to assist in inductive thematic analysis of the data.

The socio-demographic data of the study participants is presented below.

Table 1
Faculty/ Staff (F/S) Sociodemographic data
Respondent	Gender	Role	Age	Tenure at AKU
F/S 1	M	Faculty	62	> 10 years
F/S 2	M	RSU	49	> 5
F/S 3	F	RSU	42	> 5
F/S 4	M	ECM	64	> 10
F/S 5	M	PD	42	> 5
F/S 6	M	AS	44	> 5
F/S 7	F	Faculty	68	> 5
F/S 8	F	PD	39	< 5
F/S 9	M	Faculty	62	> 10
Key: RSU – Research Support Unit (staff)
ECM – Ethics Committee Member
F/S – Faculty / Staff
PD – Porgram Director
AS – Administrative staff

Table 2

Residents sociodemographic data
No:	Gender	Age (yrs)	Yrs. since graduation	Current academic affiliation?	Prior research experience?	Successful publication?
1	M	35	5–9	Y	Y	Y
2	F	36	5–9	Y	N	N
3	F	39	> 10	Y	Y	Y
4	M	34	1–5	N	N	N
5	M	40	> 10	Y	N	N
6	M	37	5–9	Y	N	Y
7	F	34	5–9	N	N	N
8	F	38	> 10	Y	N	N
9	F	31	1–5	N	N	N
10	F	33	1–5	N	N	N
11	M	32	1–5	N	Y	Y
12	F	32	1–5	N	N	Y
13	M	38	> 10	Y	Y	Y
14	F	37	5–9	N	N	N
15	M	39	5–9	N	N	N
16	M	41	> 10	Y	Y	Y
17	M	40	1–5	N	N	N
18	F	35	5–9	N	N	N
Key: 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 culture of prioritization of clinical duties over research hindered research activity.

A difficult research journey: Graduates’ experiences of conducting research and attempting to publish

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 residents 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 include 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 include 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. Lastly, 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)

We conducted this study to explore graduate residents’ experiences of research, the reasons for the relatively low rate of conversion of their dissertations into publications and to identify strategies to improve the publication rate of residents’ research in this lower income setting.

The four main findings that emerged from this study – lack of time or adequate research skills and mentorship, difficult research journeys and departmental research culture – are important pointers to the obstacles encountered by residents in carrying out research and attempting to get it published.

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 2022 study showed a publication rate of only 33%, with their residents facing similar hurdles. Obuku’s systematic review revealed a publication rate of postgraduate students’ in LMICs of 7%, with citation rate of 17% [8, 12]. 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, 10, 12–17].

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[16]. Graduating residents with a completed dissertation have three possible options. They can do nothing with it, simply leaving it in their institution’s repository [3]. Alternatively, they can attempt to get their work published on their own. A third option is to continue the pre-graduation mentoring relationship and co-author a journal article with their supervisor.

In this study, the ease or difficulty of a resident’s research journey informs their attitudes to subsequent publication. Residents with little or no prior research experience can find navigating the process extremely challenging. Those who face challenges selecting appropriate research topics, who struggle with the approval process and timelines, have difficulty in collecting or analyzing their data and feel pressured by deadlines to submit their dissertations do not enjoy their research journey and are less likely to publish [16]. This can engender a negative attitude, reducing their chances of publishing any research. Preparation of a manuscript to journal’s requirements, submitting it and responding to reviewers’ feedback is time consuming and requires time and expert mentorship [5, 18]. Residents who have already graduated may not have the time, inclination or even the mentorship to complete all the requisite steps to publication.

To mitigate this, early exposure of residents to research and research mentorship from more experienced colleagues during resident’s journey can be effective. Early exposure to research could begin at the undergraduate level – the findings of this study highlight the lasting advantage of prior research exposure for graduates. Those with prior exposure were more successful at publishing and secured academic posts after graduation.

Research mentorship would ideally be a natural, organic mentoring relationship rather than formally assigned and would continue after graduation, as graduate research is typically published two to three years after graduation[19]. It would facilitate early identification of viable research topics, avoid flawed methodology and wasted effort. It could result in greater motivation to complete and publish. 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].

Departmental research culture plays a key role in scholarship success. A culture that supports research promotes residents’ interest in it [20]. Such a culture supports faculty development and participation in research, enhancing their skills and experience [21]. Because inadequate research mentorship is a key barrier to residents’ successful scholarship [15], faculty development efforts should include both methodological and supervisor skills training, as well as grant and funding expertise [1]. It is unsurprising that faculty with more than 10 years’ tenure have significantly more publications than those with less than 10 years [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 projects; this can ease the pain of generating new topics for research. Additionally, in such department, faculty mentorship of residents’ work pays dividends – residents in this study who identified experienced mentors were better able to navigate the research process than those who did not. In lower income settings, research mentorship could work at an institutional or multi-site collaboration level: experienced or tenured researchers in other departments may provide guidance [1].

Although a majority of respondents in this study expressed a desire to publish their work, most eventually did not: when faced with some of the challenges above, they abandoned the notion of pursuing research beyond their dissertations and lost enthusiasm for publishing. This lack of follow-through after graduation is seen elsewhere in the literature[1, 13].

The age-old conflict between clinical and academic time for both residents and faculty was an important impediment to publication in this study. As in other settings, residents and faculty prioritized their clinical duties and patient care over research [17, 22]. 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, 23]. 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 felt that the broad emphasis for the faculty was on delivering clinical service and attending to patients, rather than on research. 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. Core missions of academic medical centres like AKU, N are centred on clinical service, educational and research [4]. It requires novel and sustainable approaches to financial support and partnerships for research and education to deliver each without compromising clinical service delivery [4, 23].

The study’s respondents expressed the desire for supportive curriculum changes including early, asynchronous delivery of the research skills teaching, teaching of academic writing skills and more dedicated, protected research time for residents. These are reasonable suggestions which require investment in the infrastructure to deliver a blended asynchronous research curriculum. However, increasing the amount of time allocated for residents’ research 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 [24].

This study 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 5years 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.

An original research dissertation is a curriculum requirement for postgraduate medical students in most settings [19]. Publication of residents’ research contributes to the global body of medical knowledge and increases the representation of data from lower income settings to the peer-reviewed scientific literature. There is a body of unpublished work in academic repositories that would benefit evidence-based clinical practice in LMIC settings [25].

Residents in LMIC settings want to publish their research but encounter systemic and personal challenges along the way. This is reflected in the relatively low rate of conversion of dissertations into publications. Academic medical centres in lower income settings make remarkable efforts to promote scholarly activity by their faculty and residents. Alongside institutional investments in their facilities and technology, more can be done.

The evidence from this study and from elsewhere in the literature points to two factors common to low-, middle- and high-income settings that inhibit resident scholarship: inadequate research mentorship and lack of time [2–3, 5–8]. This finding indicates that solutions to low conversion rates of student research into publications should go beyond simply increasing financial resources. Academic medical centres can find innovative ways of cultivating a positive institutional research culture and rewarding scholarship with means other than monetary.

Faculty development that helps to facilitate good research mentorship of residents by their faculty, and early exposure and training in research skills are a good starting point. Beyond that, institutional recognition of faculty and residents’ contributions to research, perhaps with periodic research awards or prizes especially for those early in their careers and for those who mentor them successfully [27]. Dirnagl and Pariente suggest that the focus of research awards should be on the quality, not just quantity. This would signal the importance of research quality and collaboration, avoiding the publish or perish philosophy [26]. Collaboration between disciplines and with other institutions is a way of enhancing output through ‘cross-fertilisation’ of ideas and skill sets, as well as sharing resources. Such interventions contribute to cultivating a positive institutional research culture and, as this study’s respondents attest, this can make all the difference to them.

The importance of research that is conducted in LMICs cannot be underestimated. Residents’ work contributes significantly to this body of work and its publication should be enabled, so that its impact is not lost to library repositories or left on the shelf.

Authors’ Reflection

It is interesting to reflect on the paradox that resident doctors are key end-users of EBM 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. Thus, innovative approaches to addressing the issue of low publications need not always be rooted in spending more money.

Authors’ Reflection

a. 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.

b. Consent for publication: Not applicable

c. Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

d. Competing interests: The authors declare that they have no competing interests

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

f. Authors' 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 and write-up of the research project.

All authors read and approved the final manuscript.

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No competing interests reported.

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You are reading this latest preprint version

An African Perspective on Publication of Postgraduate Residents’ Dissertation: A qualitative study exploring residents’ research experiences, barriers to publication and strategies to improve publication rates from Kenyan medical residents

Status:

Journal Publication

Version 1

Abstract

Background

Aim

Methods

Results

A difficult research journey: Graduates’ experiences of conducting research and attempting to publish

Departmental research culture matters

Prioritisation of clinical work over research

Publication challenges despite institutional support mechanisms

Discussion

Conclusion

Authors’ Reflection

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1