Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 12542
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents 
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 1145-1150  

Addressing research barriers and facilitators in medical residency

1 Department of Academic Affairs-Medical Affairs, Tawam Hospital-Johns Hopkins Medicine, USA Affiliate and College of Medicine, UAE University, Alain, Abu Dhabi, United Arab Emirates
2 Department of Internal Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
3 Department of Pediatrics, College of Medicine and Health Sciences, UAE University, Alain, United Arab Emirates
4 Department of Internal Medicine, Alain Hospital, Alain, United Arab Emirates
5 Department of Community Medicine, Gulf Medical University, Ajman, United Arab Emirates

Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. Satish Chandrasekhar Nair
Department of Academic Affairs-Medical Affairs, Tawam Hospital-Johns Hopkins Medicine, USA Affiliate, Post Box 15258, Alain
United Arab Emirates
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jfmpc.jfmpc_38_19

Rights and Permissions

Objective: To develop and implement an instrument to identify contributing factors and obstacles to resident research participation. Materials and Methods: Clinical Research Excellence Development in Innovation and Technology (CREDIT-20), a 20-point questionnaire, was developed through a four-stage methodology to measure opportunities and challenges to enhance participation of medical residents in research. The study was distributed to all medical residents at three Joint Commission–accredited academic medical centers in the emirate of Abu Dhabi between March 2017 and July 2018. Participant responses were analyzed and represented as mean ± standard error of mean, and subgroup analysis was conducted using Fisher's exact test. Results: In all, 314 of 380 residents completed the survey (83% response rate). Resident interest in research was high, with the majority of trainees responding that research will enhance their critical thinking (93%) and add to their knowledge of medicine (92%). Lack of protected time and lack of research methodology training were the most significant barriers. Over half of the residents cited the lack of a dedicated research budget as a program organization challenge. Age significantly correlated with resident perceptions of the benefits for conducting research, with trainees age 27 years or less indicating that they would be more likely to benefit from conducting research than their older counterparts (164 vs 128, P < 0.05). Conclusion: Improving research methodology training and dedicating structured-protected time for the scholarship are strategies to increase research output in international academic medical centers. The CREDIT-20 survey can identify specific barriers faced by trainees and assist medical educational leaders in implementing targeted interventions.

Keywords: Accreditation, CREDIT-20, medical education, scholarly activity, survey

How to cite this article:
Nair SC, Ibrahim H, Almarzoqi F, Alkhemeiri A, Sreedharan J. Addressing research barriers and facilitators in medical residency. J Family Med Prim Care 2019;8:1145-50

How to cite this URL:
Nair SC, Ibrahim H, Almarzoqi F, Alkhemeiri A, Sreedharan J. Addressing research barriers and facilitators in medical residency. J Family Med Prim Care [serial online] 2019 [cited 2021 May 8];8:1145-50. Available from: https://www.jfmpc.com/text.asp?2019/8/3/1145/254894

  Introduction Top

Postgraduate medical education provides medical school graduates with the knowledge and skills to become competent, independently practicing clinicians. A major goal of postgraduate training is to teach and inspire residents to pursue a career that contributes to their medical knowledge, through research. Medical research stimulates intellectual curiosity and promotes critical thinking.[1] Studies have shown that resident participation in research increases their appreciation for evidence-based medicine, correlates with improved clinical competence scores, encourages future careers as academics and physician-scientists, and can ultimately lead to improved patient care.[1],[2],[3],[4] Regulatory bodies throughout the world, including the Accreditation Council for Graduate Medical Education (ACGME) in the United States, the Royal College of Physicians and Surgeons of Canada, the Arab Board of Medical Specialties, and the United Kingdom's Royal College of General Practitioners, all emphasize scholarly activity as a core educational competency.[5]

However, residents face significant personal, logistical, and organizational barriers to conducting high-quality medical research. Often cited challenges include lack of personal interest, lack of faculty support, and unavailability of mentorship.[6],[7] Other hurdles include lack of knowledge and skills in statistics and research methodology, along with limited time in a schedule with heavy clinical duties.[8] In addition, institutions offer few, if any, rewards or incentives for resident research participation and funding is usually scarce.[6],[7],[8],[9],[10]

The United Arab Emirates (UAE), a small nation bordering the Arabian Gulf, have advanced as a political and economic leader in the Arab world and is a rapidly developing region for medical education and biomedical research.[11],[12] Over the past decade, hospitals in Abu Dhabi, the UAE's capital, have transformed from clinical institutions to academic medical centers. The ACGME-International (ACGME-I) accredited nearly all the emirate's teaching hospitals and the majority of their residency programs.[11],[12] Despite the focus on academic excellence, quality improvement, and evidence-based medicine, resident research productivity remains low. There have been several initiatives to increase scholarly activity, including research rotations, resident research days, and institution-wide multipronged programs.[13],[14] But without accurate data on barriers and facilitators to resident research activity, educators and administrators are unable to target meaningful interventions. The purpose of this study is to develop and implement an instrument to identify contributing factors and obstacles to resident research participation, to better inform educational leadership in an effort to develop strategies to increase resident scholarship.

  Materials and Methods Top

Clinical Research Excellence Development in Innovation and Technology (CREDIT-20), a 20-point questionnaire, was developed to measure facilitators and barriers, to enhance the participation of medical residents in research. The study was approved by the Al Ain Medical District Research Ethics Committee.

Survey development

A four-stage methodology was used to develop the questionnaire. In the first stage, an extensive literature search was conducted by the authors. An expert panel, comprising a purposive group of five members representing the fields of medical education (n = 1), public health (n = 1), biomedical research (n = 1), and two medical residents, drafted a comprehensive list of potential content areas for inclusion in the questionnaire. Delphi technique, a group consensus gathering methodology, was used to reach agreement among the expert panel.[15]

In the second stage, a focus group, consisting of a convenience sample of medical residents (n = 2), program directors (n = 2), research director (n = 1), and a physician member (n = 1), was conducted to further refine the items of the survey proposed by the expert panel.[15] Content validity index (CVI), a rating method to rank the shortlisted survey items based on the relevance and importance of the content,[14] was applied to the list. Accordingly, each member of the focus group independently scored each item of the survey instrument between 0 and 10, with higher CVI scores representing greater relevance and importance of the survey item. Items obtaining a mean score of less than 80% were eliminated.[15],[16] The revised survey was then administered to a volunteer group of medical residents (N = 20) for pilot testing after obtaining informed consent. No personal identifiers were collected from the survey respondents to link them to their responses. Participant responses from pilot testing were obtained using a 5-point Likert scale. Response options included the following: 1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree nor Disagree, 4 = Agree, and 5 = Strongly Agree. Residents were asked to assess the survey length, readability, comprehension, completion time, layout, ease of administration, and to eliminate repetitive or duplicate items. Finally, the resulting survey construct, CREDIT-20, was subjected to factor analysis to arrange the survey questions into their respective domains. The items relevant to the “facilitators” perceived by the residents to conduct research were categorized under the “Interest” and the “Benefits” domains, whereas the survey items related to the “barriers” perceived by the residents were distributed to the “Structure” and “Organization” domains. The maximum score expected for the Interest, Benefits, Structure, and Organization domains were 30, 25, 25, and 20, respectively. The minimum scores expected were 6, 5, 5, and 4 for each of the above domains, respectively.

Survey administration

The study was conducted at three Joint Commission–accredited academic medical centers in the emirate of Abu Dhabi between March 2017 and July 2018. CREDIT-20 was administered to medical residents during their classroom training sessions throughout the course of an academic year. The researchers obtained written informed consent from all participants prior to survey administration. Participants included all medical residents in all training specialties who agreed to participate in the study and signed the consent, irrespective of their postgraduate training year. Residents unwilling to provide written consent were excluded from participation.

Data analysis

Data were analyzed using SPSS Statistical Software Version 22 (SPSS Inc., Chicago, IL, USA).[15] The domains were identified using factor analysis.[17] The widely used principal component analysis (PCA) was used as the extraction method to undertake factor analysis and Varimax rotation was used to rotate the factors to better fit the data.[15],[16],[17] Convergent validity, to assess whether the survey items converged to measure a construct, was also conducted using the correlation coefficient matrix method.[15],[16],[17] The percentage of total variance by each factor was calculated, and the pattern matrix was used to identify the domains. Kaiser–Meyer–Olkin (KMO) sampling adequacy and Bartlett's tests (to assess the strength of the relationship between the variables) were also applied to the questionnaire.[16],[17],[18] The reliability of the inventory and its subscales were tabulated using Cronbach's alpha.[15],[16],[17],[18] The demographics of the study participants were recorded. Responses from the residents following administration of the CREDIT-20 survey instrument were expressed as mean ± standard error of mean, and the scales (agree/strongly agree) and (disagree/strongly disagree) were combined [19] and represented as percentage of total (N = 314) response. For the subgroup analysis, Fisher's exact test was adopted (many cell values less than 5) to determine any statistically significant demographic association with different domains. A P value of ≤0.05 was considered as statistically significant.

  Results Top

Following the literature search, the expert panel generated a 30-item survey questionnaire to assess opportunities and challenges encountered by the medical residents to conduct research in their residency program.[20] The focus group then eliminated survey items that obtained the average content validity score of less than 80%, based on relevance and importance to the residency program (data not shown). The pilot testing further refined the survey for clarity and length and ease of completion. The final construct (CREDIT-20), designed and developed by SCN at Tawam hospital, consisted of a 20-point survey that was then categorized into four domains following factor analysis. Thirty percent (6/20) of the total survey items was confined to the “Interest” domain, whereas 20% (4/20) was allocated the “Organization” domain and 25% (5/20), each for the “Benefits and Structure” domains, respectively. The average time required to complete the 20-item, CREDIT-20, questionnaire was 7 min.

CREDIT-20 survey validation

The consistency and sampling adequacy of CREDIT-20, measured using PCA, yielded a KMO measure of 0.77, indicating that the items correlated and are compact and that factor analysis will yield reliable factors. Bartlett's test of sphericity was significant and showed P values <0.001. Cronbach's α reliability assessment of each of the four domains ranged between 0.71 and 0.89. Cronbach's α for the “Interest,” “Benefits,” “Structure,” and “Organization” domains was 0.89, 0.89, 0.71, and 0.81, respectively. The overall Cronbach's α reliability score for all 20 items for the final construct was high at 0.86.

Medical resident responses

A total of 314 medical resident participants returned the completed questionnaires out of 380 trainees in the three academic medical centers, yielding a response rate of approximately 83%. [Table 1] shows participant demographics. Residents surveyed were predominantly male [56% (n = 175], with female forming 44% (n = 139). The majority of participants were under 27 years of age (172/314, 54.7%), single (197/314, 62.7%), and UAE citizens (196/314, 62.4%) [Table 1]. Participant responses to the survey items are shown in [Table 2]. Responses were high, between 4.2 and 4.5 (mean 4.39 ± 0.04), for the “Interest” domain. The residents perceived that research will enhance their critical thinking (93%) and add to their knowledge of medicine (92%). The mean response for the “Benefit” domain was 3.93 ± 0.05, with the majority of residents (96%) indicating that research will enable recognition among their peers and help them publish scientific papers. Less than half of respondents felt that the current research structure adopted by their institution contributed to the complexity of generating a research protocol (40.7%), lacked clarity in the process of research ethics review (43.3%), and caused ethics approval delays (28.9%). A majority (85.9%) of the residents indicated that having an in-house research ethics committee, as opposed to a centralized ethics committee, and the lack of continuous learning opportunities (73.5%) for research were the barriers to conducting research during residency [Table 2]. In terms of organizational challenges, residents indicated that lack of protected time (97.1%) and lack of research methodology emphasis during journal clubs (86.9) were significant barriers. The lack of a dedicated research budget (56.3%) was also considered by over half of the residents surveyed to be a program organization challenge. Over 40% of residents felt strongly about linking research productivity to their annual performance appraisals. Age significantly correlated with resident perceptions of the benefits for conducting research, with trainees age 27 years or less (164/314) indicating that they would be more likely to benefit from conducting research than their older counterparts (164 vs 128, P < 0.05). There was no significant correlation between resident gender, nationality, and marital status with any of the four domains.
Table 1: Demographics of the medical resident participants

Click here to view
Table 2: Determination of medical resident perceptions regarding the facilitators (interest & benefit) and barriers (structure & organization), for enhancing research participation, using a targeted survey questionnaire CREDIT-20

Click here to view

  Discussion Top

Academic medical centers worldwide are encouraging residents and faculty to engage in high-quality research.[21] Yet, few studies have examined the perspectives of international residents in research activity.[22],[23] Existing survey instruments aimed to enhance research in medical residency have limited applications for international residency programs, given the distinctiveness of the structure of international medical education.[20],[21],[22],[23],[24] CREDIT-20 is a quick, easy-to-administer survey tool to help educational leaders understand the specific barriers that their residents face and help guide targeted interventions to increase trainee research productivity.

Studies have consistently shown that residents appreciate research training.[25] Accordingly, our residents showed a high personal interest in participating in research activities, with the majority agreeing that research enhances clinical knowledge and promotes critical thinking. Consistent with other studies, residents surveyed cited the lack of research methodology training as a significant obstacle to scholarly activity.[1],[6] Numerous studies have determined that a strong research curriculum is a major determinant in the success of resident research projects.[26] As such, the implementation of a longitudinal research methodology-curriculum starting early in residency, with sessions that focus on developing research skills, may have a positive impact on resident research productivity. However, it has been documented that simple existence of a research curriculum does not necessarily increase scholarship.[26],[27] A multifaceted approach is necessary to optimize resident skills and research productivity.[28] It is interesting to note that younger age correlated with increased perceived benefits of scholarship, further stressing that exposure to research should take place early in residency training, and likely even during undergraduate medical education.

Multiple studies have confirmed that insufficient time is the primary barrier to resident scholarly activity, with one study reporting that only a minority of resident research projects are completed to publication.[6] Residents in our study also cited the lack of protected time as a challenge to research participation. Many programs in our hospitals have implemented a mandatory scholarly project and dedicated research blocks, with variable results. Rather than provide unsupervised block time for residents to independently pursue scholarly projects, flexibility in protected time is likely to be more beneficial. It may also be more practical to dedicate protected time for a research curriculum, with focused and in-depth skills training in statistics and research methodology.[27]

Resident respondents did not feel that a committed research budget was a significant barrier to research productivity. This is in contrast to several studies that have documented increases in resident publications after hiring of research coordinators.[27],[28],[29] It is possible that residents are not aware of the increased support and opportunities made available through a devoted statistician or research coordinator.

It is notable that nearly half of the residents surveyed felt that scholarly productivity should be linked to annual performance appraisals. Several studies have documented increased research output after a scholarly point system was implemented for residents.[30],[31] In the programs described, “points” were given for multiple types of scholarship, with higher points provided for peer-reviewed publications or conference presentations. The flexibility of the point system relieved resident anxiety around clinical research and encouraged trainees to collaborate and increase scholarly activity. The implementation of a similar reward system, and potentially linking it to yearly performance reviews, is a feasible method of encouraging scholarly output that our programs could adopt.

Our results should be viewed in light of some limitations. First, only three institutions in Abu Dhabi participated, although we believe our findings can help guide strategies to increase resident research productivity in academic medical centers worldwide. Second, a limited number of residents participated. However, residency programs in the UAE are small and this sample represents the majority of residents in training in Abu Dhabi emirate. The high response rate of 83% is reassuring that our findings accurately represent resident perceptions in these institutions. Finally, inherent to any self-report of complex issues, such as participating in research projects, are influencing factors that may not have been fully addressed by the survey, such as institutional and training program culture, faculty support and resident individual personality.

  Conclusion Top

Resident participation in high-quality research is an important objective for postgraduate training programs worldwide. Improving research methodology training, dedicating a structured-protected time for scholarship, increasing organizational support through the hiring of statisticians and research coordinators, and implementing a scholarly activity award system are strategies that could lead to increased research output in international academic medical centers. The CREDIT-20 survey can identify specific barriers faced by trainees and assist medical educational leaders in implementing targeted interventions.


The authors wish to thank Ms. Karthyayani Priya Satish (Al Daar International School) for the technical help with the data.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rivera JA, Levine RB, Wright SM. Completing a scholarly project during residency training. Perspectives of residents who have been successful. J Gen Intern Med 2005;20:366-9.  Back to cited text no. 1
Smith M. Research in residency: Do research curricula impact post-residency practice? Fam Med 2005;37:322-7.  Back to cited text no. 2
Kohlwes RJ, Shunk RL, Avins A, Garber J, Bent S, Shlipak MG. The PRIME curriculum. Clinical research training during residency. J Gen Intern Med 2006;21:506-9.  Back to cited text no. 3
Tooke J, Wass J. Nurturing tomorrow's clinician scientists. Lancet 2013;381(Suppl 1):S1-2.  Back to cited text no. 4
Moreau KA, Pound CM, Peddle B, Tokarewicz J, Eady K. The development of a TED-Ed online resident research training program. Medical Edu online2014;19:26128.  Back to cited text no. 5
Gill S, Levin A, Djurdjev O, Yoshida EM. Obstacles to residents' conducting research and predictors of publication. Acad Med 2001;76:477.  Back to cited text no. 6
Hames K, Patlas M, Duszak R. Barriers to resident research in radiology: A Canadian perspective. Can AssocRadiol J 2018;69:260-5.  Back to cited text no. 7
Levine RB, Hebert RS, Wright SM. Resident research and scholarly activity in internal medicine residency training programs. J Gen Intern Med 2005;20:155-9.  Back to cited text no. 8
Hamann KL, Fancher TL, Saint S, Henderson MC. Clinical research during internal medicine residency: A practical guide. Am J Med 2006;119:277-83.  Back to cited text no. 9
O'Brien J, D'Eon M. Re-thinking clinical research training in residency. Can Med Edu J 2014;5:e58-61.  Back to cited text no. 10
Nair SC, Ibrahim H, Celentano DD. Clinical trials in the Middle East and North Africa (MENA) region: Grandstanding or grandeur? ContempClin Trials 2013;36:704-10.  Back to cited text no. 11
Addulrahma M, Nair SC, Farooq MM, Al Kharmiri A, Al Marzooqi F, Carrick FR. Burnout and depression among medical residents in the United Arab Emirates: A multicenter study. J Family Med Prim Care 2018;7:435-41.  Back to cited text no. 12
Nair SC, Almarzooqi F, Alkhemeiri A. Research ethics in the Arab Region. In: Silverman, H. editors. Chapter “Health Research, Regulations in the UAE, Springer Nature Publishers; 2017. p. 255-66.  Back to cited text no. 13
Ibrahim H, Nair SC. Focus on international research strategy and teaching: The FIRST programme. Perspect Med Educ 2014;3:129-35.  Back to cited text no. 14
Nair SC, Satish KP, Sreedharan J, Ibrahim H. Assessing health literacy in the eastern and middle-eastern cultures. BMC Public Health 2016;19;16:831.  Back to cited text no. 15
Lynn MR. Determination and quantification of content validity. Nurs Res 1986;35:382-5.  Back to cited text no. 16
Liu RX, Kuang J, Gong Q, Hou XL. Principal component regression analysis with SPSS. Comput Methods Programs Biomed 2003;71:141-7.  Back to cited text no. 17
Parsian N, Dunning T. Developing and validating a questionnaire to measure spirituality: Apsychometric process. Glob J Health Sci 2009;1:1-11.  Back to cited text no. 18
Sullivan GM, Artino AR. Analyzing and interpreting data from likert-type scales.J Grad Med Educ 2013;5:541-2.  Back to cited text no. 19
Bammeke F, Liddy C, Hogel M, Archibald D, Chaar Z, MacLaren R. Family medicine residents' barriers to conducting scholarly work. Can Fam Physician 2015;61:780-7.  Back to cited text no. 20
Lahad A, Bazemore A, Petek D, Phillips WR, Merenstein D. How can we change medical students' perceptions of a career in family medicine? Marketing or substance? Isr J Health Policy Res 2018;7:52-5.  Back to cited text no. 21
Chan JY, Narasimhalu K, Goh O, Xin X, Wong TY, Thumboo J, et al. Resident research: Why some do and others don't. Singapore Med J 2017;58:212-7.  Back to cited text no. 22
Habineza H, Nsanzabaganwa C, Nyirimanzi N, Umuhoza C, Cartledge K, Conard C, et al. Perceived attitudes of the importance and barriers to research amongst Rwandan interns and pediatric residents - A cross-sectional study. BMC Med Educ 2019;19:4.  Back to cited text no. 23
Schiess N, Ibrahim H, Shaban S, Perez MN, Nair SC. Career choice and primary care in the United Arab Emirates. J Grad Med Educ 2015;7:663-6.  Back to cited text no. 24
Kern DC, Parrino TA, Korst DR. The lasting value of clinical skills. JAMA 1985;254:70-6.  Back to cited text no. 25
DeHaven MJ, Wilson GR, O'Connor-Kettlestrings P. Creating a research culture: What we can learn from residencies that are successful in research. Fam Med 1998;30:501-7.  Back to cited text no. 26
Lennon RP, Oberhofer AL, McNair V, Keck JW. Curriculum changes to increase research in a family medicine residency program. Fam Med 2014;46:294-8.  Back to cited text no. 27
Cogswell PM, Deitte LA, Donnelly EF, Morgan VL, Omary RA. Attitudes of radiology program directors toward MD-PhD trainees, resident research productivity, and dedicated eesearchtime. Acad Radiol 2018;25:733-8.  Back to cited text no. 28
Robbins L, Bostrom M, Marx R, Roberts T, Sculco TP. Restructuring the orthopedic resident research curriculum to increase scholarly activity. J Grad Med Educ 2013;5:646-51.  Back to cited text no. 29
Seehusen DA, Asplund CA, Friedman M. A point system for resident scholarly activity. Fam Med 2009;41:467-9.  Back to cited text no. 30
Seehusen DA, Ledford CJW, Grogan S, Kim E, Johnson JD, Stackle ME, et al. A point system as a catalyst to increase resident scholarship: An MPCRN study. Fam Med 2017;49:222-4.  Back to cited text no. 31


  [Table 1], [Table 2]

This article has been cited by
1 Medical residents: Research and publication priorities/confusions
Pugazhenthan Thangaraju,Sajitha Venkatesan
Journal of Family Medicine and Primary Care. 2020; 9(5): 2583
[Pubmed] | [DOI]
2 How and why do French medical students choose the specialty of infectious and tropical diseases? A national cross-sectional study
Nathan Peiffer-Smadja,François-Daniel Ardellier,Pauline Thill,Anne-Lise Beaumont,Gaud Catho,Lindsay Osei,Vincent Dubée,Alexandre Bleibtreu,Adrien Lemaignen,Michaël Thy
BMC Medical Education. 2020; 20(1)
[Pubmed] | [DOI]
3 Assessing the Clinical Learning Environment in an Institution in the United Arab Emirates: The Resident Perspective
Indira Kannan,Thiagarajan Jaiganesh,Satish Chandrasekhar Nair,Yaaqoob Alhammadi,Bibi Fatima Ghulam Nabi,Amani Obaid Salem Alabdouli,Hussein Sheleh
Journal of Graduate Medical Education. 2019; 11(4s): 79
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Materials and Me...
   Article Tables

 Article Access Statistics
    PDF Downloaded206    
    Comments [Add]    
    Cited by others 3    

Recommend this journal