Coyan et al Education

Implementation of a protocol to increase the academic

productivity of cardiothoracic surgery resident physicians
Garrett N. Coyan, MD, MS,a Ibrahim Sultan, MD,a,b Laura M. Seese, MD,a Danny Chu, MD,a,b
Matthew J. Schuchert, MD,a Angela Kinnunen, MPA,a and Arman Kilic, MDa,b

ABSTRACT Comprehensive Cardiac Surgery Research Protocol

to Optimize Resident Academic Productivity

Dedicated Research Mentoring Research Peer-Review Process

Objective: Academic productivity during cardiothoracic surgery residency training • Meetings every 2-4 weeks
• Paired with Academically Productive
Cardiac Surgeon
• Residents submit written project
proposals for review
• Cardiac surgery and cardiology faculty

is an important program metric, but is highly variable due to multiple factors. This • Review ideation, data analysis, and
manuscript progress
review for idea refinement and goal-
setting
• Project prioritization for analysis

study evaluated the influence of implementing a protocol to increase resident phy- Database Analytics/Statistical Support
• Core team of biostatisticians and data
Project Management Process

managers under cardiac surgery

sicians’ academic productivity in cardiac surgery. direction

• Provide both analytics support and
education/mentoring to residents on
• Progress tracked and discussed at
regular meetings
• Goals set for academic work products
statistical methodology • Project close-out and debrief
• Multiple institutional and national
database resources

Methods: A comprehensive protocol for cardiac surgery was implemented at our

institution that included active pairing of residents with academically productive Comprehensive protocol to support resident-led
faculty, regular research meetings, centralized data storage and analysis with a cardiac surgery research.

core team of biostatisticians, a formal peer-review protocol for analytic requests,

and project prioritization and feedback. We compared cardiothoracic surgery res- CENTRAL MESSAGE
idents’ academic productivity before implementation (July 2015-June 2017) versus A dedicated cardiac surgery
after implementation (July 2017-June 2019). Academic productivity was measured research protocol based on
by peer-reviewed articles, abstract presentations (oral or poster) at national cardio-
thoracic surgery meetings, and textbook chapters. project management and
mentorship principles increases
Results: Thirty-four resident physicians (from traditional and integrated programs)

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trained at our institution during the study. A total of 122 peer-reviewed articles were resident physicians’ academic
produced over the course of the study: 74 (60.7%) cardiac- and 48 (39.3%) productivity.
thoracic-focused. The number of cardiac-focused resident-produced articles
increased from 10 preimplementation to 64 postimplementation (0.61 vs 2.03 arti- PERSPECTIVE
cles per resident; P < .01). Abstract oral or poster presentations also increased, Cardiothoracic surgery programs continue to
from 11 to 40 (0.61 vs 1.33 abstracts per resident; P ¼ .01). Textbook chapters search for innovative ways to instruct residents
increased from 4 to 15 following the intervention (0.22 vs 0.5 chapters per resident; in clinical research. These principles lead to im-
P ¼ .01). provements in resident education and job pros-
pects. We show a dedicated cardiac research
Conclusions: Implementation of a dedicated protocol to facilitate faculty mentor- protocol leveraging mentorship, research re-
ing of resident research and streamline the data access, analysis, and publication sources, project management principles, and ed-
process substantially improved cardiothoracic surgery residents’ academic ucation oversite increases measurable research
productivity. (J Thorac Cardiovasc Surg 2020;-:1-7) deliverables among trainees.

See Commentary on page XXX.

Cardiothoracic surgeons have a rich history of contributing
to academic medicine as clinician-scientists. Although there
continue to be many external threats to the current and future
development of future clinician-scientists in our field
From the aDepartment of Cardiothoracic Surgery, University of Pittsburgh, Pitts-
burgh, Pa; and bHeart and Vascular Institute, University of Pittsburgh Medical Cen-
ter, Pittsburgh, Pa.
Accepted for the 100th Annual Meeting of The American Association for Thoracic
Surgery.
Received for publication May 10, 2020; revisions received Sept 7, 2020; accepted for
publication Sept 28, 2020.
Address for reprints: Arman Kilic, MD, Department of Cardiothoracic Surgery, 200
Lothrop St, Suite C700, Pittsburgh, PA 15213 (E-mail: kilica2@upmc.edu).
0022-5223/$36.00
Copyright Ó 2020 by The American Association for Thoracic Surgery
https://doi.org/10.1016/j.jtcvs.2020.09.122
(eg, limited funding, clinical productivity demands, and
administrative responsibilities), internal limitations on
career development also exist.1 Because of increasing
complexity of research methods, obtaining appropriate
research methodology training during cardiothoracic sur-
gery residency is becoming increasingly difficult.2 Howev-
er, with 76% of resident physicians in cardiothoracic
surgery programs planning to conduct research as part of
their future careers, it is imperative to address this gap in
training for future cardiothoracic surgeons.3
Because of the importance of academic research in resi-
dent education, the Accreditation Council on Graduate
Medical Education (ACGME) incorporates the conduct of
research into the Milestone program guidelines for thoracic
surgery.4 Functionally incorporating formal research educa-
tion into a cardiothoracic surgery training program can

The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number - 1

 Education
Abbreviation and Acronym
ACGME ¼ Accreditation Council on Graduate
Medical Education
prove difficult given the clinical demands and technical
training requirements that need to be accomplished in
what amounts to a short period of time.2 Traditionally,
many residents elected to participate in clinical research
projects adjacent to their clinical training, but productivity
can be limited in terms of formal development of analytics
skills and production of research deliverables limited by
lack of dedicated mentorship with this focus. Our group
identified an opportunity to increase resident physicians’
research productivity through the development of a research
protocol management program specifically aimed at devel-
oping skills in cardiac surgery outcomes research. This
study evaluates the influence of implementing a structured
research program on academic productivity during cardio-
thoracic surgery residency training.
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METHODS
Ethics
This study was approved by the Institutional Review Board of the Uni-
versity of Pittsburgh. It was classified as nonhuman subjects research and
therefore did not require informed consent.
Study Population
Resident physicians training in 1 of our institution’s ACGME-
accredited cardiothoracic surgery residency programs between July 2015
and June 2019 were included in the analysis. These periods were further
Comprehensive Cardiac Surgery Research Protocol
to Optimize Resident Academic Productivity
Dedicated Research Mentoring
• Meetings every 2-4 weeks
• Paired with Academically Productive
Cardiac Surgeon
• Review ideation, data analysis, and
manuscript progress
Database Analytics/Statistical Support
• Core team of biostatisticians and data
managers under cardiac surgery
direction
• Provide both analytics support and
education/mentoring to residents on
statistical methodology
• Multiple institutional and national
database resources
FIGURE 1. Comprehensive protocol to support cardiac surgery research implemented at our institution during July 2017.
2 The Journal of Thoracic and Cardiovascular Surgery c - 2020
Coyan et al
divided into preintervention (July 2015-June 2017) and postintervention
(July 2017-June 2019) cohorts. Our institution has a longstanding tradi-
tional (2 year) cardiothoracic surgery residency that accepts 4 residents
per year (typically 2 each in thoracic and cardiac tracks), and an integrated
6-year cardiothoracic surgery residency program that accepts 2 residents
(typically 1 each in thoracic and cardiac tracks) annually that began
more recently in July 2012. Residents in the 2-year traditional program
are not given dedicated research time during training but were historically
counseled on and involved with ongoing clinical research activities. The in-
tegrated program residents are highly encouraged (but not mandated) to
take a period of protected academic development after the third year of
clinical training in addition to routine counseling and participation in
ongoing clinical research efforts during clinical training. Seven of the 10
(70%) integrated program residents who had the opportunity to pursue
dedicated research time took at least 1 year out of clinical training during
the course of this study.
Research Protocol Development
Increasing academic productivity for cardiothoracic surgery residents
increasingly became a programmatic priority during mid-2017. During
July 2017, a comprehensive protocol specifically for cardiac surgery
research was implemented that included active pairing of interested res-
idents with academically productive cardiac faculty mentors, with regu-
larly scheduled research meetings (Figure 1). These meetings included
idea generation, data analysis/methodology review, manuscript review,
and academic presentations. Database storage and analysis was central-
ized with a core team of dedicated biostatisticians within the department,
and coordinated analytics assistance was provided to residents involved
with cardiac surgery projects. A formal faculty peer-reviewed protocol
for data analytics requests was implemented in conjunction with a project
management process to provide interval feedback to investigators and
residents on research progress. Efforts were instituted to ensure resident
participation on all outcomes research projects in cardiac surgery as resi-
dent availability dictated. During the entire study, the thoracic surgery
program continued its existing research program consisting of project
availability/cataloging and dedicated project-based faculty mentorship
to interested residents.
Research Peer-Review Process
• Residents submit written project
proposals for review
• Cardiac surgery and cardiology faculty
review for idea refinement and goal-
setting
• Project prioritization for analysis
Project Management Process
• Progress tracked and discussed at
regular meetings
• Goals set for academic work products
• Project close-out and debrief
Coyan et al
Outcomes and Data Analysis
The primary outcome measured was objective academic productivity by
residents pre- and postinitiation of our cardiac surgery research protocol
intervention. Academic productivity was primarily quantified by published
peer-reviewed articles initiated during the study period. The articles were
confirmed using PubMed and the topic of the article was classified as either
cardiac- or thoracic-focused for analysis. To minimize time-bias from proj-
ect completion to publication, we categorized the articles not by the actual
data of publication, but by the date of project completion/manuscript sub-
mission, which is recorded by both our thoracic and cardiac surgery
research programs for internal quality purposes. Abstracts accepted for pre-
sentation (oral or poster) at national medical and surgical society meetings
and textbook chapters authored by resident trainees were quantified as sec-
ondary outcomes with data obtained from institutional internal reporting
mechanisms based on conference programs available and resident self-
reporting for ACGME accreditation purposes. The average number of arti-
cles, abstracts, and textbooks per resident and overall research product fre-
quencies were compared between the pre- and postintervention cohorts.
Relative frequencies of cardiac- versus thoracic-focused research products
were examined. Continuous variables are presented as mean  standard de-
viation, whereas categorical variables are presented as number (percent).
Continuous variables were analyzed by Student t test, whereas categorical
variables were analyzed with c2 test or Fischer exact test as appropriate. A
P value<.05 was considered significant in all cases. SAS version 9.4 (SAS
Institute, Carey, NC) was used for statistical analysis.
RESULTS
Resident Profiles
During the study, there were 34 total residents training in
1 of our ACGME-accredited thoracic surgery training pro-
grams: 15 (44.1%) residents in the integrated program and
19 (55.9%) residents in the traditional program. There were
8 (53.3%) cardiac track integrated residents compared
Number of Cardiac Focused Manuscripts
Published (N = 74)
4
(5.4%)
10 (13.5%)
60 (81.1%)
Traditional Post-Intervention Integrated Pre-Intervention
Integrated Post-Intervention
A B
FIGURE 2. Number of (A) cardiac surgery– and (B) thoracic surgery–focused articles published by resident physicians before and after implementation of
a dedicated cardiac surgery research protocol, stratified by integrated versus traditional training program. (There were 0 cardiac-focused articles by
traditional-program resident physicians during the preintervention period.)
The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -
Education
with 5 (26.3%) cardiac track traditional program residents
during the study (P ¼ .108). Integrated program residents
accumulated 58 total training-years, whereas traditional
program residents accumulated 46 total training-years dur-
ing the study.
Peer-Reviewed Articles
The residents were authors on 122 published peer-
reviewed articles over the course of the study. Of these
122, on 105 (86.1%) a resident was the first author, and 9
(7.4%) had multiple residents as an author. There were
74 (60.7%) cardiac-focused articles compared with 48
(39.3%) thoracic-focused publications. Integrated program
residents accounted for 105 (86.1%) of those articles,
whereas traditional program residents accounted for the
other 17 (13.9%). Of the cardiac-focused articles, 70
(94.6%) were authored by integrated program residents
with the remaining 4 (5.4%) authored by traditional track
program residents. Overall, similar proportions of cardiac-
and thoracic-focused articles were written by residents in
each track (despite the differences in overall totals) before
and after implementation of the cardiac research protocol
(Fisher exact test P > .50 in both cardiac and thoracic)
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(Figure 2).
A greater increase in articles per resident was noted
for the integrated program compared with the traditional
program following implementation of the research program
(Figure 3). For all residents, there was an increase 0.6  1.0
article per resident preintervention to 4.1  5.6 articles per
Number of Thoracic Focused Manuscripts
Published (N = 48)
4
(8.3%)
9 (18.8%)
29 (60.4%)
6 (12.5%)
Traditional Pre-Intervention Traditional Post-Intervention
Integrated Pre-Intervention Integrated Post-Intervention
3
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resident postintervention (P ¼ .01). Traditional program
residents experienced a slight increase from 0.3  0.4 arti-
cles preintervention to 1.2  2.3 articles postintervention
(P ¼ .22), whereas integrated program residents experi-
enced a significant increase from 1.3  1.4 articles per resi-
dent preintervention to 6.2  6.4 articles per resident
postintervention (P ¼ .01).
Abstract Presentations and Textbooks
Abstracts that were accepted and presented at national
meetings as either an oral or poster presentation increased
significantly from 28 preimplementation to 55 postimple-
mentation of the cardiac research program (1.1 abstracts
per resident to 2.1 abstracts per resident; P<.01). Although
there was essentially no difference noted in traditional resi-
dent abstract submission rates pre- and postintervention, in-
tegrated program residents demonstrated increased abstract
publication rates more in cardiac than thoracic (Figure 4).
Textbook chapters authored by residents increased from 4
to 15 following implementation of the program (0.2 chap-
ters per resident to 0.5 chapters per resident, P ¼ .01).
DISCUSSION
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Study Implications
This study demonstrates that the implementation of a
structured cardiac surgery research protocol with intense
faculty mentor support can positively influence tangible ac-
ademic productivity among thoracic surgery residents.
Given the importance of understanding how to both conduct
and interpret increasingly complex scientific research as
recognized by both the ACGME and thoracic surgery
trainees, programs such as that proposed in this report
will become more important to implement and monitor
Peer-Reviewed Publications Per Resident Before and After
Implementation of a Dedicated Cardiac Surgery Research Program
7
0
All Residents Traditional Residents
Pre Intervention
(N = 20 Manuscripts)
FIGURE 3. The effect of implementation of a dedicated cardiac surgery research protocol on peer-reviewed article publications in integrated and tradi-
tional track cardiothoracic surgery residents (N ¼ 122 published articles).
4 The Journal of Thoracic and Cardiovascular Surgery c - 2020
Coyan et al
outcomes.3 The lessons learned as a result of this more
intense mentored research process include critical analysis
of study design, data gathering and handling, statistical
analysis, and presentation/communication of scientific
data. All of these are instrumental in training the next gen-
eration of clinician-scientists to lead the field of cardiotho-
racic surgery. Research productivity in residency and early
career is associated with longer-term career success in aca-
demic cardiothoracic surgery, according to Rosati and col-
leagues.5 Increasing research productivity as a resident
will allow for development of a more defined research
niche, which translates into more career opportunities,
funding options, and higher influence research discovery.6
There are several components to our cardiac surgery
research program that contribute to continued success in
increasing resident productivity and training opportunities
in research. Identification of academically active, interested
faculty with either formal training or extensive experience
in outcomes research was instrumental in establishing and
championing the program. In our case, 2 junior and 2 senior
faculty members served as primary mentors to residents uti-
lizing this program during the period of the study, with these
faculty members driving much of the cardiac clinical aca-
demic productivity during the study. The availability of a
dedicated cardiac surgery database and data handling
team allows for increased speed and ease of data extraction
to keep research momentum headed in the right direction. A
dedicated core of biostatistics experts to assist with all
stages of a study (eg, experimental design, data handling,
data analysis, manuscript construction, and review) is
imperative and should be housed within the department or
division if possible. Intentional peer-review of proposed
research questions with feedback (positive and negative)
Integrated Residents
Post Intervention
(N = 102 Manuscripts)
Coyan et al Education

Number of Cardiac Focused Abstracts Number of Thoracic Focused Abstracts

Presented (N = 37) Presented (N = 46)

4
(8.7%)

7 (18.9%)
5 (10.9%)

20 (43.5%)

30 (81.1%) 17 (37.0%)

Integrated Pre-Intervention Integrated Post-Intervention Traditional Pre-Intervention Traditional Post-Intervention

Integrated Pre-Intervention Integrated Post-Intervention

A B
FIGURE 4. Number of (A) cardiac surgery– and (B) thoracic surgery– focused abstract presentations at national meetings by resident physician authors

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before and after implementation of a dedicated cardiac surgery research protocol, stratified by integrated versus traditional training program. (There were
0 cardiac-focused abstracts presented by traditional-program residents either before or after the intervention).

improves refinement of ideas, collaboration, and allows for
prioritization of projects. A project management system
keeps residents and faculty on schedule with project idea-
tion, data analysis, and manuscript/abstract submission.
Together these factors allow for residents to be more pro-
ductive and intentional with their research experiences,
allow access to faculty and biostatistics mentorship, and
reinforce the expectation of carrying a project to comple-
tion. Adjacent fields have reported of success with dedi-
cated research programs to augment resident research
training and productivity. A study by Torres and colleagues7
demonstrated that the implementation of a similar protocol-
ized mentored research program by an orthopedic residency
program increased both the quantity and quality (as
measured by journal impact factor) of published research
articles put forth by residents both during and following
completion of residency. Taking a slightly different
approach, Shuman and colleagues8 describe a process of
an intramural mentored competitive research grant program
exclusively for residents that increased tangible research
outputs, including extramural grant applications, peer-
reviewed publications, and national presentation of data in
an otolaryngology program. Our internal medicine col-
leagues have developed the Leadership and Discovery pro-
gram for nonresearch track residents focusing on project
availability, faculty mentorship, and intermittent didactics
on research methodology; Carter and colleagues9 report
that notable increases in publications and presentations
resulted from this program. The Clinical Scholarship Pro-
gram was developed for general surgery interns using
similar methods focused on faculty mentorship and project
availability, and resulted in increased rates of project
completion and self-rated ability/confidence to conduct in-
dependent clinical research.10 Although many of these pro-
grams, like our own protocol, focus on dedicated faculty
mentorship and resident project availability and account-
ability, a major difference is the dedicated data analytics
and statistical mentorship/support from our dedicated car-
diac surgery statistical core. In addition to this level of sup-
port, the project management program that we describe
increased the level of productivity even more than what
was expected from other dedicated mentorship programs.
Although it may be resource-intensive, programs should
search for ways to implement these suggestions in innova-
tive ways to bolster trainee productivity.
Although some groups have adopted some of these
more direct interventions, organizational priority likely
plays a role in resident research productivity. This was
present in our study, as evidenced by the increase in
thoracic surgery-related publications despite the protocol
being implemented with cardiac surgery research specif-
ically. More general exposure to research education and
productivity among residents has indeed been shown
previously to influence resident research productivity.
Implementation of structured group research meetings
involving mentorship in research study design and

The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number - 5

 Education
abstract/manuscript production in obstetrics and gynecol-
ogy was found to increase resident research productivity
by Brackmann and colleagues.11 Similarly, Holoyda and
colleagues reported that implementation of a quarterly
research meeting for faculty and residents to discuss pro-
jects and presentations increased resident productivity in
a plastic surgery program.12 These findings imply that
programs can increase resident research productivity
and interest even from simple interventions when re-
sources to support a larger effort such as described in
our study cannot be identified, although this is an area
in need of future study.
A major finding in our study is the significant increase
in productivity of our integrated program residents as a
result of the initiation of our cardiac surgery research pro-
tocol. The differences in ultimate career goals, including
proclivity for research-oriented specialties and careers,
has been a topic of discussion for some time.13 Given
these differences, the major difference likely comes
down to exposure. Integrated program residents have the
benefit of longitudinal exposure to both faculty mentors
and special protocolized programs. In our early integrated
program experience, we found that those integrated
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program residents completing research time continue to
have increased academic productivity based on de novo
projects during their senior training years, and this has
been propelled by our dedicated cardiac surgery research
protocol. Additionally, the 3 integrated program residents
who did not elect to take dedicated research time also
had significantly increased academic productivity after
program initiation. Given the low number of residents
thus far, further research will be needed to define this
trend completely. Our traditional program residents histor-
ically have taken some protected time for research during
general surgery residency before commencing thoracic
surgery training. However, the productivity of this time
is highly variable and sometimes not within the field of
cardiothoracic surgery. Some surgery programs have suc-
cessfully adopted cardiothoracic surgery laboratories
funded by the National Institutes of Health T-32 program
to encourage early protected cardiothoracic surgery
research among surgery residents; however, the number
of positions available remains limited.14 Although it ap-
pears that select traditional program residents in our
program were able to take advantage of our newly insti-
tuted research program, the program has benefitted our in-
tegrated program residents to a much greater level. We
have re-focused our efforts recently on including tradi-
tional program residents in the program at the outset of
residency, and early indications of project completion
appear promising. Further research will be needed to
discern how to improve research training and mentoring
experiences of our traditional program residents, who
only train for 2 years at our institution.
6 The Journal of Thoracic and Cardiovascular Surgery c - 2020
Coyan et al
Limitations
This study describes a single-center experience with
implementation of a dedicated cardiac surgery research
protocol with good faculty and program commitment;
this type of program may require different implementa-
tion formats in different institutional climates to achieve
the same results. The implemented protocol was primarily
for cardiac surgery outcomes research only; there was no
change to the thoracic surgery research program or any
change to the basic science program in cardiothoracic sur-
gery. However, many of our integrated program residents
who participate in basic science research experienced
increased productivity with their adjacent clinical
research as a result of the program. Our experience de-
scribes both integrated and traditional 2-year training pro-
grams; the difference in time in training and resident
allocation likely had a confounding effect on our study.
We do not have data on any differences that might have
become evident in 3-year traditional programs or 4 þ 3
combined general/thoracic surgery training programs
for this type of program. We may have missed certain
research deliverables in our searches due to delayed pub-
lication long after program completion, but this should be
minimal because residents report detailed active research
efforts to our program director on a yearly basis for
ACGME reporting. Finally, there may be some lag-time
bias and in reporting for abstracts and textbooks specif-
ically due to the self-reporting measures employed that
was not present in the peer-reviewed publications data,
which were more rigorous in our study. Additionally,
complete authorship order was not available for these
work products.
CONCLUSIONS
Implementation of a structured cardiac surgery research
program facilitating mentoring of trainee research signifi-
cantly increased measures of academic productivity among
thoracic surgery resident physicians. The longitudinal na-
ture of the program seemed to benefit integrated program
residents to a greater degree due to amount of time exposed
to the program. Further research is warranted to determine
what types of specific interventions can target increasing
traditional track thoracic surgery trainee exposure and op-
portunities to conduct research while maintaining clinical
training rigor.
Conflict of Interest Statement
Dr Kilic receives consultant fees from Medtronic and Dr
Chu receives consultant fees from the Japanese Organiza-
tion for Medical Device Development, Osler Institute, and
Wolters Kluwer Health. All other authors reported no con-
flicts of interest.
Coyan et al
The Journal policy requires editors and reviewers to
disclose conflicts of interest and to decline handling or re-
viewing manuscripts for which they may have a conflict
of interest. The editors and reviewers of this article have
no conflicts of interest.
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8. Shuman AG, Kohrman DC, Corfas G, Bradford CR. Implementation of an intra-
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Key Words: surgical education, research education,
research protocol, cardiac surgery research, resident
productivity
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7
 Education Coyan et al

000 Implementation of a protocol to increase the academic productivity of

cardiothoracic surgery resident physicians
Garrett N. Coyan, MD, MS, Ibrahim Sultan, MD, Laura M. Seese, MD, Danny Chu, MD,
Matthew J. Schuchert, MD, Angela Kinnunen, MPA, and Arman Kilic, MD, Pittsburgh, Pa

A dedicated cardiac surgery research protocol based on project management and mentorship
principles increases resident physicians’ academic productivity.
EDU

The Journal of Thoracic and Cardiovascular Surgery c - 2020