Welcome to today's webinar. I'm Dr. Heidi Harvey, the moderator for today's webinar. Before we begin, I'd like to share that we will be taking questions at the end of the webinar. But in addition, Dr. Shepard has agreed to take questions during the webinar as time allows. You can submit your questions at any time by typing them into the Q&A section located at the bottom of the event window. Today's webinar is titled Establishing a Productive Resident Research Program and being presented by Dr. John Shepard. It's my pleasure to introduce Dr. Shepard. He received a master's in clinical research while an FPMRS fellow at the University of Pittsburgh. He joined the faculty there after graduation and built his early career around mentoring fellow and resident research and became the director of resident research. He moved to Hartford, Connecticut three years ago where he became the associate residency program director and adopted his techniques for a new system and environment. Through this transition, he found certain themes continue to emerge that may make resident research successful. And today, he'll be sharing them with us. Thank you. All right, so just wanted to welcome everybody and thank you for joining the webinar. Throughout my career, I have been in positions where most of the research that I've done has been with residents. And so I was asked about a year ago to talk about what had made me successful in resident research and kind of had to think about it and say, well, you know, what are the things that I think matter and what are the things that are reproducible? And that's what I hope to get out of this is to show you guys some of the techniques I've used to find ways that you may be able to implement some of these things in your programs, either with fellows or residents or both. And I, you know, when I was in Pittsburgh, I was in a system where I had both residents and Uragan fellows, and in my most recent job, I've had just residents with the exception of a MIG fellow. So I think that these can apply to both of those systems and can also be applied to medical student research if you're working with them as well. So I have no disclosures or conflicts of interest. And for the overview, these are the main points is that we want to figure out how we can outline our goals for why we're doing the research, how we can maximize the motivation of both the mentors and the mentees, find a way to identify appropriate mentors, use the existing skill sets of the mentees and how they can translation or translate those into things that they can do with their research, work with a captive audience. And that's kind of talking about how we can use the things that we have around us as tools as opposed to trying to find new things that we may not have access to. And the last thing is baby steps. The resident research projects don't have to be New England Journal of Medicine quality articles. They oftentimes are smaller, less aggressive, more time-efficient things for the residents to work on. So if we go back to outlining our goals, we got to ask ourselves, why are we here with these residents or fellows, and what are they looking to get out of this research experience? So I put this slide in because I'm a big basketball fan, a huge North Carolina Tar Heels fan. And I remember that I have been trying to dunk since I was, you know, able to walk essentially. And I could touch the rim by the time I was in the sixth grade and kept jumping and jumping and trying to get higher and higher. But you got to set reasonable goals for yourself. And apparently I was never made to be somebody who would dunk. But I had somebody teach me that you don't aim to get the ball over the rim. You aim for the top of the square. And then if your jump falls a little bit short, you're still there. Physically limited in getting there, but just think about how we want to set our goals. So set your goals for your residents. Set aggressive goals. And then if they fall short of them, if time falls apart, if life gets in the way, if something happens, you can still be successful in getting their things completed in the time frame that they have. So I remember one of the things that somebody once said to me is that, man, research sure is hard. And then, and this is actually one of my fellows when I was at Pitt. And then this can also be translated to research sucks, which was a statement that followed up the research is hard one shortly thereafter when a couple other things happened with the project. So yes, it's going to be hard. Yes, there's going to be times when the mentor and the mentee are not going to like the research project. And, you know, the relationship can get strained there. But just think that there is a goal in mind and keep those in mind. And so the other thing that I remember is that when I was a fellow, Matt Barber was still at Cleveland Clinic. And one of the things he told a good friend of mine who was there was that there's no unpublishable papers. There are only those that have yet to find the right journal. And I think that if you stick with this mantra, that's how you get things published from resident research is, you know, you may not get the first article published in the first journal. It may not be the second. And I think that the first article I ever published was actually like in the fifth or sixth journal that we submitted to. So choose an appropriate journal, but also if it doesn't go through, don't get discouraged and figure out what you can do to improve the paper and resubmit it. That's my number one take home here is that you can get these things published for sure. So what does the ACGME say our goals are? The goals are that each program must provide an opportunity for residents to participate in research or other scholarly activities and residents must participate actively in such activities. So this is a graduation requirement. So you've got to have something set up in your program where residents can accomplish these goals. Now, you'll notice that it says scholarly activities. I'm currently working with one of the residents here on a review paper, one that I was asked to write. And so I got her involved in that because she was struggling to find research that she was passionate about. And we had talked a little bit about recurrent UTIs, and this is what the review paper is about. So she's writing that. But I still think it's better to actually pursue what would be classically considered more standard research projects for your resident research. So I sit down with each of my residents on a yearly basis and meet with them and make sure they're meeting a timetable. And we first sit down, I do it during the first couple weeks of their intern year. And we look at it and say, what are your goals with these research projects? What do you think that you're going to accomplish and what can we get out of this? One of the things some people say, I want to work on something I've already started, I've already been involved in. Some people say, I want to be a NIH-sponsored funded researcher someday, and I want to lay the groundwork now for learning techniques that will help me out onto a research career. Some people, you know, our program has about, you know, 15 to 20 percent of our residents will go on to fellowship here. When I was at McGee, it was much higher than that. So some people are trying to position themselves for a fellowship application, and they may not need just one, but two, three, or four research projects to be completed to make themselves competitive. Another thing you may want to do is, they may want to learn about an area of personal interest. So I say, you know, what are the topics that you find interesting to you? What are the things that you know about and you want to explore more? There may be other things that you say, listen, we don't get a lot of this in our training, and I know that this is going to be important for me to be a good OBGYN, so I'd like to do a research project in this to figure out how I can learn a little bit more about this so that I'm a little bit better prepared. Other people might have a goal to publish a paper. I try to make that a goal of all of our residents, whether they know it coming in and they know it's starting or not. Because if you're going to put all the work in, you might as well get the credit on PubMed for having done the work. But ultimately, there's going to be some residents who are going to look at this as a graduation requirement and something they have to fulfill in order to complete the program. And so, you know, knowing these goals going in will help you kind of set up the project and tailor it to the individual goals so that they're going to get out of the research what they want. If you have somebody say, oh, I'm going to put you in a position to be an NIH researcher, and they really don't care about research and they just want to do it as a graduation requirement, it's not going to work out for you. You've got to align your goals with theirs. And I think it's very important to find out what they want to get from the research before you even start. So the next thing that we want to do is take those goals and motivate our learners for success and motivate our residents, our fellows, to where they can reach those goals and make those goals attainable. And I really think that that is partially our job as the mentors and partially their job as the mentees. We both have to find the right mix of motivation, the right mix of pushing and supporting while at the same time allowing them to spread their wings a little bit. And ultimately, it's their project. So they've got to maintain that motivation for this to be successful. So this is one of the classic picture about motivation. And I think that this holds true when we talk about residents for research and when we talk about residents and fellows clinically. We've got to find the thing that turns their wheels and gets them going, the thing that's going to get them invested in the project. And we've got to find that right carrot. And for me, I think that my enthusiasm carries over into their enthusiasm and vice versa. And it's very easy for me to be motivated when I've got researchers who are also motivated because it puts us on a common goal and a common pathway. I did have a time a couple of years ago when I went and sat down with my chairman and said, you know, I'm really working really hard to try to motivate people. And I don't seem to be connecting with them. And I'm having trouble finding the right carrots to get them to chase. And he looked at me and said, John, sometimes this picture applies, but sometimes you just need to use the stick instead of the carrot. So keep in mind that it's about motivating. But at the same time, we're in charge of these residents for their education. And sometimes they just need to be pushed a little bit. And sometimes you have to use the stick as opposed to trying to find the right carrot. So this is another picture that I always kind of chuckle about because as you will see, this is kind of a common picture in just about any checkout line at any grocery store in America. And, you know, we may not be pushed right against these as much as we were with social distancing now and standing back a little bit further, but they kind of try to prod you into getting stuff. And I remember that my son was with me when he was younger and we were at the grocery store. He's like two or three years old. And he kept asking and asking and asking, can I have some of the candy? Can I have some of the candy? And every single time I said no. And then one day I finally, I was tired. It's the end of a long day. I just want to get out of the grocery store. I'm ready for him to stop nagging me. I said, okay, you can have a candy bar. And since that day, he has never once stopped asking me for candy bars because he'd kind of quit asking for a while. And then when I yielded, he knew that he could get it eventually. So he keeps prodding me more and more for them. So I get asked for candy bars a lot. My point here is, is we've got to find the right things to motivate our residents, but also keep in mind that whatever precedent you set will be held for future residents too. They're going to remember those things. And, you know, in the programs that I've been in, one of the things that we did historically is that we've said if one of the residents has a meeting, a presentation accepted at a meeting, they go to the meeting. They're relieved of their clinical duties, allowed to go to the meeting for a couple of days. And I find that to be a very good motivator. If your programs can afford it and your chairmen are in line with that, I think it's a great motivator to get people to say, you know, most of these meetings are in nice places. We're talking like in the Urugan world, the SGS is always in the spring when everybody's getting sick of the winter and always tends to be in a nice resort location. So I think that those can be very motivating things for our learners. All right. So we go from finding their motivation and finding their goals. And I'm going to skip back to the goals for just a second. I do think that setting those goals early and setting a timeline is highly effective in making sure that you are able to accomplish those goals. It's very easy to come in and, you know, the interns get busy. Next thing you know, it's Christmas. They haven't even thought about research. You start talking to them. Then the next thing you know, it's the end of the first year. They don't even have a project yet. So I have a timeline that I go through and I use with my residents. And I really want them to have a mentor and a project, a mentor and an idea by the end of, you know, kind of by Christmas. And by the end of the first year, have the actual project kind of outlined. And then by Christmas of the second year, so it's kind of like a semester timeline, Christmas of the second year, Christmas of the second year, we want them to have their IRB submitted. And as we all know, that means that maybe you'll have your IRB approved by the end of the second year. And that gives them the entirety of their third year to collect data and analyze data. And in our system, we do have a resident research day that's shared for all the programs in Connecticut. We have a shared resident research day that is in the fall of each year, but it's kind of a competitive process, much like OGS or SGS would be. And that you submit abstracts, they score them, they pick the best ones for oral presentations. And so our timeline is set up to have their project done by the end of the third year so that they can work on that abstract and get it turned in for that. And I think that enforcing the timeline and meeting with them on a regular basis is key to making sure that you kind of keep them on this track, because it's very easy to fall off the track. And my timeline always has built in kind of redundancy and built in extra time so that I anticipate they're all gonna fall off the timeline at some point. And I tell them from day one, whatever you think it will take you to do, plan on that, but then double the time. Like if you think it's gonna take you two months to get your IRB, you should plan on four months. If you think it's gonna take you a month to write this protocol, plan on two. And so keep in mind that things are gonna take longer. As we all know, I assume everybody on the webinar is invested in research at some level or you wouldn't be here, but you all know that research just always takes longer than you think it's going to take. So the next thing that I have them do is to utilize their existing skill sets. So, I don't know. John, one question if you don't mind. Besides presenting at conferences, which paid for, what are other carrots at work? Currently, we have no funding for faculty, fellows, et cetera, to go to conferences for the next year plus. Right. Um, like for me, that's been the most effective carrot. And if you can't do that, I think that you could potentially negotiate with your chairman for, you know, maybe an extra day off or something like that. Add to their vacation by a day. But I also think that the sticks are highly effective there too. And throughout this timeline, I have checkpoints where you need to be to a certain thing by a certain place and time. And using the stick more than the carrot there can be effective. Like, hey, you're not here. We got to get this work done. One of the things that I do is I have a dashboard that we have a monthly faculty meeting and department meeting. And one of the things that I forward is the dashboard that shows where people are in the timeline. And so there's like, you know, 10 different steps in the dashboard. And you can see, you know, obviously the chiefs are going to be further along in the third and second years, but you can see within the class where everybody is. And I find that that's a good motivator as well for them to see that they're falling behind their peers and for that to be put up in a public forum. I don't want to get into shaming people, but I do feel like it's important for them to recognize, hey, you know, here was the goal that we had for you. Here's where everybody else is. Here's where you are. And I, you know, we're all very competitive people. So I think that that does help. So. There other things that I've seen is like prizes for publications can be monetary prizes. You've, you know, right now funding's at a low everywhere, but if faculty members are willing to, you know, chip in whatever it is, a hundred bucks a piece, and then have this fund that gets divided against amongst people who get published by the end of the year or people who get presentations, those are other ways to make that happen is what I've seen. I've never really employed those myself personally. So, so using your existing skillset, I don't know how many people have seen the Liam Neeson Taken movies, but I saw at least the first one, maybe the second one. And one of the quotes from that first movie really stuck with me. It says after his, and to give you like a brief synopsis of the movie, his daughter is abducted and they're, you know, holding her for ransom and they don't realize that he's like a former hit man, essentially. And he says to somebody on the phone, who's asking for a ransom, I don't know who you are. I don't know what you want, but I, what I do have are a very particular set of skills, skills I have acquired over a very long career, skills that make me a nightmare for people like you. And one of the, you know, kind of tongue in cheek here, but one of the things that sticks with me about this quote is that we all have an abundance of skills. We all have a very particular set of skills and skills that have been acquired over a very, very long time point at this point. You have operative skills, you have administrative skills, you have research skills, you may have statistical skills. And those are the things that I like to kind of bring in and say, what are your skills? What do you have? And what can you do both for the mentor and for the mentee? Like, and you can employ those skills to make the projects more successful. So in looking at our mentees, this is also part of the worksheet that I go through with them is looking at their goals, looking at, you know, what they may be interested in, looking at people that they may have met and want to work with. But we say, what are your skills? What can you do that maybe the other people in the room can't do? We've got people who are MD, PhDs, and they may have basic science research background. They may be able to do like PCRs or Western blots or things like that, that, you know, it may be one person per class that's able to do that. They can take those skills and transition them into a research project that will be functional and publishable and serve as their resident research project. Now, and when I was at Pitt, we had kind of within the Research Institute, Joel Sadowski, who kind of administrated the Research Institute always had projects that were waiting to be done. And he just needed somebody to be involved with them. And so some of our residents who had these skills would take, you know, take those projects up and do them. Other people would go over there because they want to learn how to do those things and would work with somebody. And we did have a research block during that residency program. And some programs have that, some programs don't. I do think that it's helpful, but I also think that you need to be very careful with it because it can be wasted time if it's not overseen appropriately. But the same thing to be said there is that some of these things take a long time and may be better served for a fellow than a resident, a fellow who's got a block of time where they can be in the lab for months on end. And to do it with the resident is pretty difficult, to be quite frank with you, from a time standpoint to get the basic science done. So I don't really push those a lot. Other people may have statistical skills. One of my favorite stories is that I was working with a resident a couple of years ago and before she went to medical school, she had been the head biostatistician for the state of Nevada. And I found this out. I was like, you're golden. She wanted to be an MFM fellow. I was like, you're golden. All you had to do is take these statistical skills. The one thing that gets caught up in a lot of projects is people not being able to finish their statistics. I was like, so if you can provide that service, you're gonna get on an unlimited number of papers and judging from the skills you probably have, it's not gonna take you that long. And she's like, well, I really got out of it because I didn't wanna do that anymore and I wanna do medicine. I was like, well, do it for a short period of time, use it as a skill to get you where you wanna go. Your goal is to be an MFM fellow, use that skill. And she did and she published multiple papers which she was involved with because she had this skill that other people didn't have and other people couldn't pay for, did not have the grant money to pay for and she could provide it for free and get involved in the project and get authorship. And now she's an MFM. So use the skills that you've got. Other skills you may have, you may have worked in databases or manipulation of those. You may, people may already know how to do, write IRBs which makes that step of things easier. People may know how to do grants. One of the things that we have at our institution, which I assume a lot of institutes should probably have is they have like seed money and small grants. I have really pushed our residents to apply for those grants and they've been super successful in getting them because a lot of these small grants as we know, they're small grants so they're not super competitive and it's a good process for the resident go through the grant writing process to get some funding that way there's no issues with getting statistics done. There's no issue with getting supplies and it's another thing for their resume. So if they're looking to do a fellowship, hey, I was funded this grant. And so look for those small grants within your institutions. Oftentimes through the school of medicine or research institutes still will have these small grants. So we're talking, you know, a thousand bucks, maybe two, maybe less. So it's not a huge deal, but for their CV, it can be a big deal. So the next thing that I push on my residents is that they really need to find an appropriate mentor. And I think that we all, everybody listening today is probably going to be on the same page with that is that mentors are where you get to the next step. And if you knew how to get to the next step already, you'd already be there. So you need somebody to help you to get to that step. And so I talk with my residents a lot when they come in about who the mentor is and how they're going to choose that mentor. And, you know, some programs assign those mentors, some programs wait and let the residents choose a couple of months in once they've got a chance to know people. But I ask them a lot of questions like what, and once again, getting back to what are your goals, where do you want to be and what motivates you? Some people like to have a mentor that's really on top of them and really pushing them. Other people don't like to have that kind of scenario and they'd rather have a little bit more autonomy to do things at their own pace and speed. And, you know, they've got to find somebody that's going to support that. And the other thing that I find is that people get locked into mentors. And it's, and I tell them all the time, it's like, this is your career, this is your education. If your mentorship is not working for you, work with me. Let's find a way to make it more appropriate. Let's make it more productive. And if we can't, then just move on. And there's no harm in moving on to a new mentor. So one of the things, I don't know how many people recognize this ring, but, and if we were doing this as a live presentation, I'd have a show of hands, but this is the ring from the Lord of the Rings. And, you know, one of the quotes on there is one ring to rule them all, if you've read the books or seen the movies. And I think that when it comes to mentoring, this is the antithesis of what you actually need. There is no one ring to rule them all. There is no one perfect mentor. And I think that like a lot of people get locked into that and like, oh, I have found my mentor, or here is who my mentor is. And they often state that as a non-plural sentence. It's a single mentor. And I encourage people, I push them strongly not to go for a single mentor. Find like, there is no person that can get you all the things that you're lacking. You're gonna learn certain things from different people. You're gonna get certain skills from different people, but no one person is likely to be the one person that can do everything that you need. So you're going to need multiple mentors. And, you know, the program that I have been in for the last four years, one of the things that they struggle with is they did not have a ton of people who knew how to do research. And they didn't, they had people who were interested and people who had some good ideas from a faculty member perspective, but they didn't have a ton of people who knew the nuts and bolts of how to get it done. So that's kind of largely been my role. So if you're somebody who does have that, you know, the research background and knows how to get stuff done and knows how to make stuff function, take advantage of that. Use that as your skill. Because there may be people in your program who have ideas that just don't know how to get to the next step. And you can become a mentor, not only for the residents, but also for other faculty members. And I'll tell you that like the last time I checked, I had, you know, I think like eight or 10 IRBs that were open where I was the PI that were obstetric IRBs. And I haven't done obstetrics in, you know, well over a decade at this point. So I was the research mentor for the resident. The resident also had a clinical mentor. And so we kind of combined the aspects of both, somebody providing the clinical, like what the research question is in the field today. And there was things that I'd kind of lost touch with because of being out of obstetrics for so long. But I knew how to take those things and apply the research modalities to get to the answer that we could get to a publishable statement at the end. So I encourage your trainees to have multiple mentors. And I would also say, encourage yourself to have multiple mentors. So this is a picture, this is quite an old picture at this point. This is when I started fellowship, this was the faculty members when I was at Pitt. And one of the reasons I put this picture in was because I specifically remember realizing that each of them had different things that they were working on. And at the time I was like, well, I'm not really sure what I want to do. So I think I'm just going to try to work with everybody. And so before my fellowship was over, I actually did a project with every single one of these faculty members. And like to this day, I rely on different ones of them for different things in mentorship and different. And I still collaborate with several of them, even from a distance. And of that picture, three of them have moved on to other institutions that kind of spread out around the country. And we still communicate and collaborate and work on research projects. And I have skills that I can offer them, they have skills they can offer me. And to this day, we were kind of relying on each other for that mentorship. John, question. Yes. What basic department infrastructures are needed for a good research program? Okay. So a couple of things that I think are necessary. One is you got to have the buy-in of the department and administration. And if it's not a priority for them, it's going to be more difficult for it to be a priority for you and the residents. The good news is that the ACGME requires this. So if you have a residency program, you kind of have to have the research. Other things that I think are important is like some sort of time, whatever that may be, like figure out a way to work it into your contracts to get some time that's protected away from clinical duties. Because, you know, clinics get busy. You've only got so much time in your day. And once that day's over, we've all got families and friends and outside activities. And so like, if you can work into your schedule to have some protected time, I think that becomes super helpful. And I also understand that it's less easy to do. And for those who may be in private practice looking to do some research, it becomes a more of an economic hit for any time that gets taken away from clinical time. But I do think that that's important. And then one of the other things that I would say is you need to have some sort of relationship with a statistician, because that's a lot of projects, that's where they get hung up. And for me, like I've done a good bit of my own stats over the years from the master's training that I got. And if you have that ability, you should exploit it, because you can use that ability with other people to help them out. And it's an easy way for you to get more publications by providing that kind of that service and working on the infrastructure of how projects get done. If you don't have that, you just got to figure out how to get it. And if you've got those seed grants, a lot of times most of the residency grants, that's what I've encouraged them to do is most of the budget goes towards the statistician. And we're a community hospital that has a relationship with one of the statisticians at UConn and pay her on like an hourly basis. And so that's where like that money goes to that. But like a lot of projects can get hung up at the statistician level. And that's the person that you really wanna make sure that they're happy with you. You're taking them coffee cards or donuts or whatever, find what their carrot is and keep them happy because statisticians often will have three or four projects that they're working on. And you want their relationship with you to be the one that they like enjoy. And that yours is the project they pick up first when they've got several on their desk. So this project, this picture here actually comes from like a wealth management website talking about exponential growth. And showing how you invest a little bit and then you grow your wealth. But I think that mentors and mentees, when you encourage your mentees to look for that mentor, tell them that the most important thing is finding somebody who's invested in them. And if you're somebody who is mentoring the faculty on how to be a good mentor, like the best advice that I can give them is be available for your resident researchers and put them first. Like I look back on my days as a fellow and there were some faculty members who would be more responsive and some faculty members who would be less responsive. And that information kind of filters around quickly to the fellows and to the residents. And they figure out very quickly who's more willing to help them and more able to help them. And those are the people that they go back to time and time again. So it's a two-way street on an investment. You've got to be invested in them. And then in return, they're going to be invested in you and they're going to come work with you. And the thing about, for those of you who have fellows, having Urugon Fellows is a huge blessing because you have somebody who is very smart, very capable and very well-trained and who has a third of their time dedicated to research. And there's not many other positions that you're going to have somebody that capable that's going to have that amount of time. So keep your fellows happy at all costs. It will pay dividends in the end. And that's, if you're looking to advance your own career, the easiest way to do that, I think, is to keep your fellows happy. You'll get involved in a lot of projects. You're going to be highly rewarded for that experience and they're going to be very happy with you. And it's going to be a very good win-win situation for everybody involved. But if you're just working with residents and you're advising them, tell them that the most important thing about finding a good mentor is finding somebody who's invested in you. So there's a quote that says, there's no limit to what you can accomplish if you do not care who gets the credit. I think this is attributed to Ronald Reagan. And that's why I say, if you're the faculty member and you've got trainees, invest in them. They'll get the first author, you'll get the senior author. It may reduce the number of podiums that you're physically on, but it will increase the number of podiums that your work is on. Let your trainees get the credit and it'll pay dividends in the end. And the next thing is, your success will be determined by your availability more so than your ability. And I think that what this comes down to is that I tell our residents all the time, I don't expect you to know the answers. I expect you to show up and I expect you to work hard. I expect you to try to learn every single day. And I think that goes for clinical training as well as research. We shouldn't expect them to know how to do the research. We should expect them to be at least as invested in it as we are. So this is a graph that I came up with because I'm a math guy and I like numbers and numbers speak to me. But one of the things that I've found is there does seem to be a linear relationship between a mentor's research ability and their available time to invest in their trainees. Like the highest level researchers have all the knowledge in the world, but they may be so busy that they can't really invest in their trainees. And so as a trainee, what you should be looking for is somebody who splits the difference. And I think of this as, if you're a four on the available time scale, but you're a one on the research ability scale, multiply those together, you're at four times one is one. And the flips out of that one times four is still four. But if you maximize this in the center, you can kind of get to a two and a half and a two and a half. And somebody who's in the middle on ability and in the middle of time is probably gonna be your best bet for a mentor because that two and a half square is gonna be higher than four times one or one times four. So one of the old jokes is the best way to become successful in life is to choose your parents wisely and that you're getting the right DNA contribution, which everybody knows this is impossible. But when we talk about mentoring, the best way to become successful in research is definitely is to choose your research mentors wisely. And those people can contribute to you. They're not passing on any genetic information like your parents, but the environmental impact cannot be understated of how important that is. So the next thing that I say is to work with a captive audience. Stay within what you're good at, what your institution has and what you have available to do research on. So one of the examples I give, and Gary Sutkin who was in that picture a couple of slides back has moved on from Pitt and is now at the University of Missouri, Kansas City. And I gave a similar talk out there. And so I use this as an example today. We had a resident when I first started in Hartford who wanted to do research on vulvar cancer. And you can see here that there's not much vulvar cancers. New cases is 2.5 women for 100,000 women. High five-year survival, but the new cases are very low and the deaths are even lower. So I extrapolated this to his Kansas City residency program. They've got a population there of about a half a million people. And if you apply that 2.5 per 100,000 people per year, says you should get somewhere in the neighborhood of about 12 cases of vulvar cancer per year. But what's the odds that they're gonna come into your office and not another one in a different part of the city and be interested in participating in the research that you're gonna do and for residents be able to do that at the time when the resident's actually there. It's like close to zero. So the flip side of this argument, and I told the resident who wanted to do vulvar cancer research, I was like, this is not a good choice for you. There's not even gonna be enough to do a retrospective case series. We should pick something else. But if I look at that UMKC graduating class, their graduates have done 400 deliveries and with 800, eight residents a year, that you're looking at 3,300 deliveries per year that are done there. If they do about 100 hysterectomies, each is a graduating chief and eight residents per year, there's about 800 hysterectomies per year being done at that institution. And this is much higher than those 12 vulvar cases, cancer cases that you're gonna catch. And so I push residents, like, listen, C-sections, vaginal deliveries, hysterectomies, those are your bread and butter. Those are the great things to do research on. Even though a lot of it's been done already on them, those are where you're gonna have your captive audience. Another question is how many patients come into the resident outpatient clinic a year with vaginal discharge? I had a resident a couple years ago who said, hey, we're using this affirm test. We send it out, it takes a couple days to get it back. We're doing a web prep, but we don't have pH paper in the clinic because of CLIA lab certification issues and maintaining it. And so she wanted to look at, say, how much better would we do in diagnosing BV and other things from discharge if we just had the pH? I said, that's a great idea because there's gonna be a lot of that coming through. So work with your captive audience. And whatever you have at your disposal, different places are gonna have different things. I know when I was at Pitt, our MFM service had essentially a whole service that was doing methadone conversion in pregnancy. It was, people would come from all over the country to do that. It's a great area of research because not many other places are gonna have a captive audience like that to catch those people with. Other things that happen within your institution, policy changes. We had a resident who was, and he, interestingly enough, has like four daughters and all have been home births, which I've always questioned that plan, but he was very interested in natural therapies. And one of the things is he was really pushing for delayed cord clamping when he first got here. Well, we had a policy change in the hospital where they moved forward with a policy of delayed cord clamping. And so we looked at that and said, okay, let's see what happens before, what happens after. And we have just recently submitted that for publication. So find those things that you have in your institution and capitalize on them. So the next thing that this is a cave wall painting that I forget exactly where it is, but it was something about the length of the fingers told us who our ancestral origin was and how far back it went. But the reason I put this picture in here is that many hands make light work. And so if you're looking at those captive audience, things that you have a lot of, one resident may not be able to go through those, what do we say, 3,300 deliveries or 800 hysterectomies a year. But if you get 10 residents that have 10 different ideas and can collect data for all 10 projects, those numbers get cut by tenfold. So, and I love these group projects where we've had, I've had a lot of success, we've had a sacral complex database that I started when I was at Pitt that people keep coming up with new project ideas, keep adding variables to the database, keep going through and updating the database. And we've published, I'd say, at least 10 papers off that one database. Same thing happened at Pitt with the C-section database. They had 10 residents came together with 10 different project ideas, were able to collect data for 10 projects, set it all up, did one data search, everybody had to contribute their equal number of patients. But I think that those group projects work very well for, and the key there is also getting multiple projects out of it. Set it up initially, if you think you're going to do a retroactive database, figure out if there's a second research question you can ask and do 10% more work and do twice as much publication power. So, and this is just talking about those two things, the sacral complex database, the minimally invasive sacral complex database that I had at Pitt that we've been very successful in getting multiple things published off of in the same C-section database. So, if you are of a certain age, which is about my age, somewhere in that 40 to 50 range, you'll recognize instantly that this is Vanilla Ice and these are the two Grammys that he won back in the day. But he got in a lot of trouble for sampling and ended up having to pay a lot of money to Queen for copying their work and copying the beat for some of their music. The reason I put this in here is because a lot of times in research we do not completely copy, but use other people's ideas. And that's one of the things that I love about going to Augs, the meetings, is I'll sit there and say, oh, that's a great idea for a project, and we can tweak it and answer a slight, you know, answer a different question with a very similar setup. And I get, a lot of times I get some of these ideas and do spinoff projects from ideas that other people had. One of the things that comes up is there was a lady, and she was actually in New Zealand, who looked at body mass index, and she was looking at this, and I said, well, that's a great idea. But, and she pretty much cut it off as obese versus non-obese. And so, I called her up. We ended up Zooming. It was, she was having her morning coffee and I was getting ready to go to bed. And we started doing another project to see if we could use a receiver operator curve to find out exactly where the tipping point was. It may not be that it was obese or non-obese. Another thing is that there was a project presented a couple of years ago at Augs on healing suggestion. And with sacral complexes, they read a script to say, you know, you're going to wake up pain-free, you're going to get out of bed, as anesthesia was being induced, and then track pain scores and see if healing suggestion in a randomized trial made a difference. And I called these, you know, I checked with them after the meeting and said, listen, you didn't find anything for healing suggestion, but you've got a very good resource there for looking at pain scores. And, you know, there's narcotic epidemic right now. And so, we went out and we used their data set and were able to go back in and figure out how many narcotic tablets the average person needed after a sacral complex, which is super helpful information right now. And so, we were able to take one project and kind of spin it into something else. And this is where I've, like, collaborated with other people. So, go to those meetings, talk to people, and say, hey, I've got an idea. Could we work with you? Could we do this a different way? Could we use this data and answer another question? And just to prove that I'm not the only person who does this, this is a paper that we published. Dr. Carter Brooks is one of my fellows at Pitt. And we looked at the robotic team and how it impacted sacral complex outcomes and how, like, staff turnover in the OR and things like that mattered. And then, similar, there we go, looking at a very similar question out of Northwestern. They were able to answer a very similar question to ours. And so, people, like, people do this all the time. They'll find other people's ideas and spin them slightly differently to ask a different research question. And I think it's a great way to come up with research projects. So, one of the things that I would say is that residents, a lot of programs want the residents to come up with their own projects. I don't think this is always the best idea because they are very early in their career. I think it's kind of upon us to come up with some of these ideas. So, one of the things that I do is I keep a, almost a library of possible topics. And I email the faculty every year and say, hey, if you come up with any research ideas in the last six months, send them to me. And I keep the library. And when people in the middle of the time come up with an idea, hey, this is a great idea, I'll send it out. The resident says, hey, so-and-so's got this idea. They're looking for somebody to work with them on it. And that's how I kind of get that flow of project ideas. I will go to meetings. I'll come up with ideas. I'll come back and I'll present them to our residents. I think that you guys should really work to help them come up with their own ideas. Some of them are going to have their own ideas. Not all of them will. And I think it's helpful if you can provide them with a potential idea if they're not able to come up with one of their own. All right. So we, the election is bearing down on us. And, you know, now we actually know who's running as of yesterday was the VP. But I put this picture in here to remind you that policy changes and political hot spots and political ideas are very compelling for research. And so some of the ideas that I've had is like back when the Affordable Care Act came through, we postulated that there would be more people getting access to Urugon care and that that would improve, you know, Urugon care delivery. But then one of the things that we found was that people get their care, but then they were tending to have higher co-pays and higher co-insurance, like they're going to pay 20 percent. So, yes, they come for their visits. They get all the way to surgery. And then, you know, the surgery cancellation rate was going up as a result of the Obamacare and an Affordable Care Act being implemented. And so these things, you know, there's other things out there. Domestic violence. I worked on a project actually with an undergraduate student. She did it as a class project looking at domestic violence and urogynecology. Opioids, a big deal right now, a national public health crisis. Marijuana, if you're in a state that has legalized marijuana, if you're in a state that's got medically legalized marijuana, or if it's illegal, that gives you three different setups to see how marijuana can impact some of the things that we treat. C-section rates, always a hot topic. If you can find something that you have done that's going to improve the C-section rate, it's going to be almost instantly publishable right now. So things that have political significance can be things that are going to be more likely to get you published in the end. So I really push for those. I think that they're great ideas. A lot of our residents are good activists and good people that are good advocates for women, and so they're interested in a lot of these ideas already, and they make great resident research projects, in particular if there's policy changes that you can do a pre-post design. So this picture is here showing that this plant is growing someplace in the desert, and it has found a way to grow because it's found a way to get a little bit of shade and a little bit of sunlight and be sheltered a little bit from the storm. I'm introducing this as the thought of a niche, and this is more for the faculty members than for the residents and the fellows themselves, and essentially for the people on the webinar tonight. Find your niche. Find the place where you can grow unobstructed from other people. And so one of the other things about niches is the nice thing about niches is it allows people to flourish in slightly different nearby environments that lack competition. So these oyster catchers are not fighting with the flamingos because they're right at the border between the sand and the water as opposed to in deeper water. So find your niche, and I'm going to pull off from that picture from before that I had of my faculty member. We had people with different niches. We had Helena was the PFDN PI, and so she was doing a lot of randomized surgical trials. Pam O'Alley was doing a lot of basic science research. Gary Sutkin was doing a lot of educational research. Jerry was doing a lot of database research and decision analysis research, and Katta Getty was doing a lot of elderly research and mental health research related to urogynecology. They each had a niche where they didn't have to compete with each other, and that way allowed the division to be more supportive. But find the niche and find what your division needs or your institution needs and fill it, and fill it with a skill. Try to find a skill that you have that's not being provided otherwise, and that's going to make you invaluable as you mentor the residents as you work with them on their projects and your own projects, frankly. All right, the next thing is baby steps, and I think that a lot of residents come in saying, you know, I'm going to do this. I'm going to have a randomized control trial, and I have seen people pull that off, but it is extremely difficult. So you've got to figure out a way to convince them this doesn't have to be the biggest project ever. Small projects are good projects. And so one of the things I think about is one of my favorite movies from, oh my gosh, probably 25, 30 years ago now, is Mr. Holland's Opus. But in the movie, if you're not familiar with it, Mr. Holland spent his career teaching, and he was a music teacher, and he thought that he had not made as big of an impact because he worked with students, and he worked with, you know, smaller stuff like the symphony that played or the plays that get performed. But what you didn't realize was that he was making a huge impact on those kids' lives, and I think that we make a huge impact on our trainees' lives, and I also think that the projects that they do have a huge impact in the field. So this is a classic level of evidence diagram, and one of the things that I really push my residents is to stay away from those top levels. Those case series are great resident research projects. Case control studies, individual cohort studies, these are the things I really push on them because a lot of these are things that can be done on their own time, nights, weekends, if they've got an hour free in the middle of the day, can be pulled from medical records, they don't have to have any direct interaction with patients, it makes for a much easier IRB. So if you can focus on these three, the case series, the case control studies, and the cohorts, it is going to make you far more successful because they're going to eliminate a lot of the obstacles that our residents face, which are time-based or system-based. We can get around a lot of those by focusing on these things of research. How many people know who these guys are? And if you need a hint, I'll throw this up there too. So this is Watson and Crick, and the reason I put this picture up here is to think that, you know, Dr. Watson, I believe it's Dr. Watson, not Dr. Crick, was a graduate student at the time that he discovered DNA and won a Nobel Prize for it. And so the other thing is, I tell our residents all the time, don't sell yourself short. You can do things that can be impactful to the healthcare of women at the resident level. And part of that is because you see things a little bit differently. And I'll give you a couple of examples here. HPV vaccinations, we within the last few years, I had a resident come to me and she says, you know, every, and she's an intern at the time, she said, every single time I round on somebody postpartum, I have to check and make sure their rubella status is immune before they can go home or it's malpractice. And she says, and every single one of these women is eligible for the HPV vaccine, and it can prevent cancer. And we're not even asking about that. We ask about rubella, why do we not ask about HPV? So we started asking about it. We developed a survey that we are in the process of writing the abstract and the paper form of things to look at people's knowledge and whether there were racial disparities or other instances that led to changes in their knowledge or changes in their willingness to get the HPV vaccine. And if, you know, ultimately, if they're willing, it then becomes a funding thing. And we can make big social change if we can find funding to get HPV vaccine to be administered in the postpartum setting. Other things that we did is I've looked at the Hassan versus varies, because for entry needle, I had one of my residents ask me like, hey, why do you use this when somebody else uses this? What's the difference? And so I told them, like, let's study it. And so we looked at different things. And some of that had already been done, obviously, but we try to take a slight step back and say, hey, what's the difference? We try to take a slightly different slant. Another resident was asking me, okay, you're doing a sacral colpexy. We did two today. One lady had a hysterectomy done at the same time. The other lady had had a previous hysterectomy. What's the difference there? I was like, well, you know, that's interesting, because we've got a whole database that we can answer this question with. So we, and I hadn't, I thought I'd thought of everything that could possibly answered out of that database. And she came up with a new idea just from seeing one day in the hour with me. So they see things a little bit differently. And a lot of times these make for great resident research projects. And I'll tell you that two of the ones on this list are already published from the last three or four years. And I think that at least one of the other two will get published as well. So even though you're taking baby steps and trying to do smaller projects, don't sell yourself short. And tell your residents they can really impact clinical care if they'll express their ideas and we need to foster those ideas. And that's a lot of times I'll sit with people and say, OK, I want you to spend the next three weeks, the next three months and figure out something that you're interested in, something that you didn't understand. Come back to me and we're going to see if we can make that your research project. So and it pays big dividends because it tends to be something they're interested in as well. All right. So as we move on to the end of this, I just want to go back and kind of reassess those six major points. And I think that are going to make you highly successful. And they've worked for me. They've worked for me in two different institutions with different residents and trainees with different levels of goals, different levels of motivation. But if you outline the goals of why they want to do it, if you find out a way to maximize their motivation to achieve those goals, help them find the right people to get them there as they use new skills that they're learning from those mentors, as well as skills that they already have and to find an appropriate project that is going to be accomplishable within the confines of their knowledge, their mentors knowledge and what the institution can provide and to not think too big, but also not to think too small. And I think that those things are going to get you to a successful place as you start to do your resident research in your institutions. So thank you. I put this picture in here very specifically because this is a lot of people think of like the end of the presentation is the sunset. But this is actually this is it between Alton, Snowbird and Utah. And this is actually the sun rising. And this is the sun rising over the ridge behind me and starting to shine on this mountain in the background here. So hopefully this talk will be something that is going to ignite in you the ability to go out and accomplish more with resident research at your institutions. And this will be the sun rising on that in the future. So thank you. Well, thank you, Dr. Shepard for your presentation. We have a few more minutes for questions. And if you haven't already done so, you can submit your questions for Dr. Shepard and the Q&A section at the bottom of the event window. Our next question is, with COVID, a lot of clinical research was is on pause. Do you recommend staying away from clinical research currently? So think back to that level of evidence chart that I showed you. Yes, a lot of IRBs are putting interactions with patient on pause. My understanding is that most IRBs are not going to have any problem with retrospective research where you're not interacting with patients where there's no true intervention. And I think that these projects tend to work better for resident and fellow research anyways, because it allows them to do the research on their own timetable. So I would say, yes, I think that COVID is going to impact how we view clinical research moving forward. Does that mean it has to impact all research? No, definitely not. How do you balance or integrate resident and fellow research? Well, I think that the answer to that is very much like how do we integrate fellow and resident participation in the OR, right? We have a system where the fellow can do the fellow part of the case and the resident can do the resident part of the case. And there's generally a knowledge gap and experience gap, even in research between a fellow and a resident. And I think that a lot of times they can work on projects together and kind of symbiotically both get a lot out of the project. Now, it tends to be the fellow is doing more of the work because they've got more of the time to do it. And so it tends to be that the fellows are the ones getting the podium for the presentation and the ones that are the first author. But for most residents, being second or third author is fine. And having something on the CV for having been on a podium, even if they weren't the one physically staying there, is also fine. So I think that you can integrate them together. But they also tend to ask separate questions. So fellows want to invest in almost like a deeper level of research question. And so the questions don't always overlap. And so you can combine them on the same project or you can keep them on separate projects and just let them do different projects. And that's what I tended to do more of when I was at Pitt. We have any more questions? Oh, here we go. For a PMRS fellow, what number of research projects do you expect over three years? So I think that that's kind of specific to the program itself. Because different, like there's obviously programs that are more invested in the clinical experience of the fellows and programs that are more invested in more and expect more from the research side. We typically, like our expectation was that you would have two things to submit to AUGS every single year, to submit to AUGS every single year, which would give you six projects over the course of three years. Now, granted, you're probably going to have some projects that you're wrapping up out of residency. And some of these projects, you probably won't finish by the end of your fellowship. But I think that, you know, six, five to six is probably like a reasonable expectation. But I think that varies from one institution to the next. Like if you're if you're an institution that is currently most of your fellows are finishing with two projects, maybe you shoot for three. If you're, you know, if you're already at five to six, maybe you say, okay, we want to get like whatever your goals are. And that's where you've got to tailor the goals to your individual institution as well. Well, on behalf of the AUGS Education Committee, I'd like to thank Dr. Sheppard and everyone for joining us today. Our next webinar is titled Pelvic Floor Myofascial Pain and Dysfunction, Etiologies, Associated Symptoms and Strategies for Assessment. And we'll be presented by Dr. Jerry Lauder and Dr. Melanie Meister on September 16. Well, thank you, everybody. Thank you, Dr. Sheppard for your time. And thank you all.

webinar

resident research program

Dr. John Sheppard

clinical research

resident mentoring

clear goals

appropriate mentors

existing skills

captive audience