|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 1 | Page : 11-15
Research in surgery and anesthesia: Challenges for post-graduate trainees in Uganda
Alex E Elobu1, Andrew Kintu2, Moses Galukande1, Sam Kaggwa1, Cephas Mijjumbi3, Joseph Tindimwebwa3, Anthony Roche4, Gerald Dubowitz5, Doruk Ozgediz6, Michael Lipnick7
1 Department of Surgery, Makerere University College of Health Sciences, Kampala, Uganda
2 Department of Anesthesia, Makerere University College of Health Sciences, Kampala, Uganda
3 Department of Anesthesiology, Mulago Hospital, Kampala, Uganda
4 Department of Anesthesiology, University of Washington, Washington, United States
5 Department of Anesthesiology, University of California, San Francisco, United States
6 Department of Pediatric Surgery, Yale University, Connecticut, United States
7 Department of Anesthesia, University of California, San Francisco, United States
|Date of Web Publication||31-Jul-2015|
Alex E Elobu
Department of Surgery, Makerere College of Health Sciences, Mulago Hospital Complex, Mulago Hill Road, P. Box 7103 Kampala
Source of Support: None, Conflict of Interest: None
Background: Research is critical to the training and practice of surgery and anesthesia in all settings, regardless of available resources. Unfortunately, the output of surgical and perioperative research from Africa is low. Makerere University College of Health Sciences' (MakCHS) surgical and anesthesia trainees are required to conduct research, though few publish findings or go on to pursue careers that incorporate research. We believe that early career experiences with research may greatly influence physicians' future conduct and utilization of research. We therefore sought to analyze trainee experiences and perceptions of research to identify interventions that could increase production of high-quality, locally led, surgical disease research in our resource-constrained setting. Methods: Following ethical approval, a descriptive, cross-sectional survey was conducted among anesthesia and surgery trainees using a pretested, self-administered questionnaire. Data were tabulated and frequency tables generated. Results: Of the 43 eligible trainees, 33 (77%) responded. Ninety-four percent identify research as important to career development, and 85% intend to publish their dissertations. The research dissertation is considered a financial burden by 64%. Also, 49% reported that their departments place low value on their research, and few of the findings are utilized. Trainees report that lack of protected research time, difficulty in finding research topics, and inadequate mentorship are the main challenges to conducting research projects. Discussion: Our anesthesia and surgery trainees spend considerable resources on research endeavors. Most have significant interest in incorporating research into their careers, and most intend to publish their work in peer-reviewed journals. Here we identify several challenges facing trainees including research project development, financing and mentorship. We hope to use these results to improve support in these areas for our trainees and those in other resource-limited areas.
Keywords: Anesthesia, global surgery, research, Sub-Saharan Africa, surgical training, training
|How to cite this article:|
Elobu AE, Kintu A, Galukande M, Kaggwa S, Mijjumbi C, Tindimwebwa J, Roche A, Dubowitz G, Ozgediz D, Lipnick M. Research in surgery and anesthesia: Challenges for post-graduate trainees in Uganda. Educ Health 2015;28:11-5
|How to cite this URL:|
Elobu AE, Kintu A, Galukande M, Kaggwa S, Mijjumbi C, Tindimwebwa J, Roche A, Dubowitz G, Ozgediz D, Lipnick M. Research in surgery and anesthesia: Challenges for post-graduate trainees in Uganda. Educ Health [serial online] 2015 [cited 2020 May 30];28:11-5. Available from: http://www.educationforhealth.net/text.asp?2015/28/1/11/161826
| Background|| |
Despite recent reports that surgery and perioperative care in Sub-Saharan Africa (SSA) have been relatively neglected as health priorities, there is limited literature focused on surgical and anesthesia training and practice in the region. Research is an integral part of surgical and anesthesia training and practice, and findings have the potential to shape interventions to reduce the great burden of surgical disease in the region. ,,,,,,,
Improvements in mortality, morbidity and disability among the global poor will require locally driven, collaborative research and also the translation of these findings to policy and practice.  Unfortunately, research capacity and output in surgery and perioperative care is low in SSA. , Causes include limited infrastructure and other resources for research,  high clinical work load competing for faculty and learners' time, inadequate research training, limited funding and lack of a guiding government policy ,,
A recasted role for the surgeon in Africa has been previously proposed to include time equally shared between clinical work, teaching, research and advocacy for surgical services;  such a framework would also extend to anesthesiology. There is therefore an increased need to improve the research capacity of individuals involved in the delivery of surgical and anesthetic services. ,,,,
MakCHS is one of ten medical schools in Uganda and one of four that provides post-graduate training programs for surgery and anesthesia. Specialist training at our institution takes place through the Masters of Medicine (MMed) pathway previously described elsewhere.  As in other British-derived education systems, post-graduate trainees are required to write a dissertation based on original research work.
Postgraduate training provides these future specialists with significant exposure to the conduct and utilization of research. We believe that a trainee's initial experiences with research affect their future conduct and utilization of research, yet no analysis has examined the trainee experience with research in our context. We therefore sought to characterize post-graduate anesthesia and surgery trainees' attitudes, experiences and self-reported challenges with conducting research. We also discuss strategies that may increase the research capacity and output of these trainees during and after their training.
| Methods|| |
Following ethical approval, this descriptive cross-sectional survey was carried out among post-graduate trainees in anesthesia and surgery at MakCHS in September 2012, for program assessment and planning purposes. The curriculum and setting of our anesthesia and surgical training programs have been previously published. 
Content validity of the questionnaire was established through expert panel reviews and focus groups. Residency class leaders and a sample of local and international surgical and anesthesia faculty were polled for relevant topics in areas including international collaborations,  research experiences and perceived quality of training. The analysis presented in this paper covers the research component of that survey. The self-administered survey was piloted, refined, re-piloted and then administered to consenting second- and third-year trainees. First-year trainees were not asked to participate given their limited exposure to the conduct of research at the time of this study. Socio-demographic data were collected. A Likert-type scale was used to measure trainees' attitudes, experiences and challenges with research. Also, phone interviews and Internet searches were conducted using a structured questionnaire to determine whether dissertations completed between 2000 and 2012 were published or presented at conferences, as well as to assess the author's perceived impact. The survey data were manually entered (in duplication) and validated using EpidataEntry 3.1 ("The EpiData Association" Odense, Denmark, 2008). Data analysis was done using Epidata Analysis Software ("The EpiData Association" Odense, Denmark). Proportions were calculated and continuous data were summarized as means or medians where applicable.
| Results|| |
Of the 43 eligible trainees at our institution, 33 (77%) completed the questionnaire. Their basic demographic characteristics are documented in [Table 1].
Although the majority (81%) of the trainees have scholarships for their MMed training, only 35% of these scholarships cover research fees. Up to 72% of trainees must fund their research dissertations from their pocket [Table 2].
|Table 2: Attitudes toward and experiences with research among post-graduate anesthesia and surgery trainees at Makerere College of Health Sciences|
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The majority of respondents (94%) agree that research is an important part of their career, and 84% intend to submit their dissertation work to a peer-reviewed journal for publication.
On the other hand, only 12% of the trainees have published in peer-reviewed journals, and 28% have engaged in collaborative research with a visiting/international group [Table 3].
|Table 3: Challenges faced by post-graduate anesthesia and surgery trainees at Makerere College of Health Sciences|
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The two most common challenges reportedly faced by trainees are selecting a research topic (82%) and the lack of protected time for research (70%). Inadequate research training and mentorship were additional challenges reported by half of the trainees [Table 4].
The departments of surgery and anesthesia recorded 66 dissertations conducted between 2000 and 2011. From available data, 57% of the dissertations were disseminated through peer-reviewed journals, and 28% through conference presentations.
| Discussion|| |
This survey shows that majority of the MMed trainees in our Ugandan school have a positive attitude toward research and are interested in publishing their research work. However, their experience with research faces challenges of funding, mentorship and training among other hurdles. Numerous prior surveys have evaluated similar topics in trainees from high-income countries, ,, though, to our knowledge, no similar survey has been published evaluating trainees from a resource-constrained setting. Next we discuss the results and propose potential solutions to the challenges highlighted by this survey.
Attitudes toward research
Ninety-four percent of those surveyed agree that research is an important part of their career, confirming significant interest among trainees in this area. Whereas only a few have published previously, 84% intend submit their dissertations for publication. Historical analysis of dissemination of previous dissertations shows that only 57% of theses between 2000 and 2012 were published, and only 28% presented at conferences. The high proportion of unpublished dissertations during this time period could be due to several factors including quality of the research, cost of publication, lack of time, and lack of mentorship among many other potential reasons. The discrepancy between high intention rate to publish and the modest publication rate suggests further examination of this area and likely additional support to help trainees disseminate their work is needed.
Whereas 79% of respondents noted that their programs place high value on engaging in research, half perceived low value attached to actual research output. This may occur if research is in low-priority areas. An analysis of previous dissertations showed that 60% were perceived by the dissertation authors to have had positive impact, mainly by contributing to the body of scientific knowledge.
Nearly half of trainees agree that research is important for post-training employment. In Uganda, specialist employment opportunities often include a mix of private practice and public service, with relatively fewer academic jobs that allow focus on education and research. While academic institutions value research in faculty recruitment and promotion, its immediate value in public service or private practice is less clear. The importance of research in public service should be clearly emphasized so as to stimulate more enthusiasm for practitioners to conduct research.
Experiences and challenges with research
Overall, the conduct of research among the trainees seems to be burdensome. Only 52% perceived that they were adequately mentored to conduct research. Similar mentorship challenges for research and surgical competency training have been reported among Kenyan trainees.  Currently, students identify a potential research topic, then a faculty supervisor. This may be advantageous, as mentee-initiated mentorship relationships are thought to be most productive and long lasting.  However, the perceived lack of mentorship may stem from limited surgical  and anesthesia research capacity,  and faculty who may not be adequately supported to be effective mentors. Our Departments of Anesthesia and Surgery have only 6 (out of 15) and 10 (out of 33) faculty, respectively, who qualify to mentor post-graduate trainees. With a faculty to student ratio of 1:4 due to a large increase in the number of enrolled trainees in recent years and the heavy burden of clinical service, faculty have limited time for research mentorship. ,
Nearly two-thirds (64%) of respondents specified that dissertations are a financial burden. Trainees commonly spend US$ 2000-4000, which is in addition to annual tuition fees (US$ 2500) and is 5-10 times the national annual per capita income or 25-50% of a starting specialist surgeon's annual salary. In our context this is a considerable cost.
Financing of post-graduate training has repeatedly been identified as a bottle neck to specialist training in many institutions,  yet funding is an enabling factor for research. 
Although 81% of the trainees have scholarships, only 35% cover research costs. The respective departments need to explore ways to attract funding for post-graduate research projects.
Selected international grants may be applicable, but there have generally been fewer sources of funds for surgery.  International academic collaborations are another potential source of research funding. ,, Though a large number of international research projects are conducted at our institution, only 28% of participants reported participating in collaborative research with international groups. Anecdotally, few such projects identify local principal investigators or route significant financial support for such projects through local departments. Advocacy for equitable distribution of research resources for international collaborations is needed. 
Only 7% of dissertations conducted by post-graduate trainees surveyed were based on previously conducted work. This indicates a need for deliberate efforts to follow up and utilize prior research findings. A research agenda and database of priority research areas/topics as well as a list of previously conducted research projects (including unpublished studies) in each discipline may increase use of the knowledge generated, inform future projects, decrease duplication of efforts and shape policy and practice. ,,, This potentially improves patient care and outcomes and is rewarding to the researcher and motivating to other potential researchers when they are able to see the difference their researches make [Box 1]. ,
With a clear research agenda, a research question bank can easily be developed. This would likely address the primary challenge reported by 80% of respondents of difficulty in getting a research topic. For example, it has been observed divisions/units in the department of surgery that develop and maintain a research question bank tend to attract more trainees.
Starting the dissertation in the first or early second year may also allow better distribution of the trainees' time during training, and partially address the issue of lack of protected research time identified by 70% of the trainees. The issue of protected time (time period during the course dedicated to a particular activity) may require a broader look at the curriculum to determine its feasibility. Some training institutions in the USA allow trainees up to a year of research or additional master's programs. ,,,,
Inadequate research training was specified by half of the trainees as a challenge and has been reported among faculty surgeons as well. Additional training options for the trainees and faculty should be evaluated and implemented.
This study evaluated the perspectives of trainees and as such the findings are an expression of opinion. Although this is a single institution study, we believe the opinions expressed are an accurate representation of the trainee experience in Uganda with applicability elsewhere in the region. The challenges discussed in this article relate to shortages of human resources for health and are common to SSA. Nonetheless, generalization of these findings to training institutions in SSA and other settings should be done cautiously.
Conclusion and recommendations
Our anesthesia and surgery trainees have significant interest in conducting and publishing research, as well as formally incorporating research into their career paths. However, they report many challenges to achieving these goals including insufficient funding, mentorship, training and local consensus on priority research areas. Based on our findings, efforts to address these challenges are underway with the goal of improving local research capacity and output.
| References|| |
Madiba TE. The value of research in surgery. S Afr J Surg 2007;45:115-20.
Ko CY, Whang EE, Longmire WP, Jr., McFadden DW. Improving the Surgeon′s participation in research: Is It a problem of training or priority? J Surg Res 2000;91:5-8.
Kaushansky K. ASCI Presidential Address: Mentoring and teaching clinical investigation. J Clin Invest 2004;114:1165-8.
Luboga S, Galukande M, Mabweijano J, Ozgediz D, Jayaraman S. Key aspects of health policy development to improve surgical services in Uganda. World J Surg 2010;34:2511-7.
Luboga S, Macfarlane SB, von Schreeb J, Kruk ME, Cherian MN, Bergstrom S, et al
. Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group. PLoS Med 2009;6:e1000200.
McQueen KA, Ozgediz D, Riviello R, Hsia RY, Javaraman S, Sullivan SR, et al
. Essential surgery: Integral to the right to health. Health Hum Rights 2010;12:137-52.
Nordberg E, Holmberg S, Kiugu S. Output of major surgery in developing countries. Towards a quantitative evaluation and planning tool. Trop Geogr Med 1995;47:206-11.
Galukande M, Ozgediz D, Elobu E, Kaggwa S. Pretraining Experience and Structure of Surgical Training at a Sub-Saharan African University. World J Surg 2013;37:1836-40.
Hanney SR, Buxton MJ. Global IDEA. CMAJ 2005;172:1538.
Lavy C, Sauven K, Mkandawire N, Charian M, Gosselin R, Ndihokubwayo JB, et al
. State of surgery in tropical Africa: A review. World J Surg 2011;35:262-71.
Musa J. Generating evidence for surgical practice in Africa: The role of clinical research. Afr J Paediatr Surg 2012;9:62-5.
Galukande ML, Kijjambu SC. Improving Recruitment of surgical trainees and Training of Surgeons in Ugand. East Cent Afr J Surg 2006;11(Number 1).
Luboga S, Galukande M, Ozgediz D. Recasting the role of the surgeon in Uganda: A proposal to maximize the impact of surgery on public health. Trop Med Int Health 2009;14:604-8.
Elobu AE, Kintu A, Galukande M, Kaggwa S, Mijjumbi C, Tindimwebwa J, et al
. Evaluating international global health collaborations: Perspectives from surgery and anesthesia trainees in Uganda. Surgery 2014;155:585-92.
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.
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.
Holmes JF, Sokolove PE, Panacek EA. Ten-year experience with an emergency medicine resident research project requirement. Acad Emerg Med 2006;13:575-9.
Mutebi MC, Raja AJ. Mentoring the modern African surgeon: A call to arms!. Ann Afr Surg 2011;7:16-9.
Ford HR. Mentoring, diversity, and academic surgery. J Surg Res 2004;118:1-8.
Burton K, Howard A, Beveridge M. Relevance of Electronic Health Information to Doctors in the Developing World: Results of the Ptolemy Project′s Internet-based Health Information Study (IBHIS). World JSurg 2005;29:1194-8.
Lavy C, Sauven K, Mkandawire N, Charian M, Gosselin R, Ndihokubwayo JB, et al
. State of surgery in tropical Africa: A review. World J Surg 2011;35:262-71.
Lipnick M, Mijumbi C, Dubowitz G, Kaggwa S, Goetz L, Mabweijano J, et al.
Surgery and anesthesia capacity-building in resource-poor settings: Description of an ongoing academic partnership in Uganda. World J Surg 2013;37:488-97.
Chu KM, Jayaraman S, Kyamanywa P, Ntakiyiruta G. Building research capacity in Africa: Equity and global health collaborations. PLoS Med 2014;11:e1001612.
Rothberg MB. Overcoming the obstacles to research during residency: What does it take? J Am Med Assoc 2012;308:2191-2.
[Table 1], [Table 2], [Table 3], [Table 4]