|Year : 2019 | Volume
| Issue : 4 | Page : 208-214
Publishing determinants and barriers among family physicians during and after training in Saudi Arabia
Sulaiman Abdullah Alshammari1, Abdullah Sulaiman Alshammari2
1 Health Promotion and Health Education Research Chair, Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Senior Student, College of Medicine Imam Muhammad Ibn Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||4-Oct-2019|
Sulaiman Abdullah Alshammari
Department of Family and Community Medicine, College of Medicine, King Saud University, P.O. Box 2926, Riyadh 11461
Source of Support: None, Conflict of Interest: None
Objective: This study aims to examine the topics covered and the type, scope, and methodology used in family physicians' research projects. In addition, this study explores the determinants and barriers to publishing that affect family physicians' publication behavior. Methods: This study reviewed the end of training research projects of family medicine residents in Saudi Arabia in 2012 and 2013 to determine their topics, scope, and methodologies. Participants were followed for 5 years. Residents' attitudes toward publishing, percentage of work published in peer-reviewed journals, whether participants continued to publish afterward, and obstacles to research and publication were assessed. Results: Residents (n = 157, 66.7% of men) completed an electronic self-administered questionnaire comprising information about training, sex, and publication history. Seventy-six (48.4%) successfully managed to publish in peer-reviewed journals. Most employed questionnaires in their projects (93%) and used descriptive statistical analysis (94.3%). A smaller number of family physicians (n = 15, 9.6%) continued to publish after completing training and resuming family medicine service. Most published projects (95.8%) employed a cross-sectional design. Some (n = 60, 38.2%) expressed interest in publishing if they received an expert's assistance. Reported obstacles to publishing included lack of time (19.1%), unavailability of technical support (14.0%), and lack of incentives (3.1%). Conclusion: Overall, participants' attitudes toward research and publication were positive; however, their publication rate after completing a training program was low. Publication should be promoted through continued education about research and writing methodology and through incentivization of professional mentors and financial support.
Keywords: Family physicians, primary care, publication, research, residents
|How to cite this article:|
Alshammari SA, Alshammari AS. Publishing determinants and barriers among family physicians during and after training in Saudi Arabia. J Nat Sci Med 2019;2:208-14
|How to cite this URL:|
Alshammari SA, Alshammari AS. Publishing determinants and barriers among family physicians during and after training in Saudi Arabia. J Nat Sci Med [serial online] 2019 [cited 2019 Oct 22];2:208-14. Available from: http://www.jnsmonline.org/text.asp?2019/2/4/208/260447
| Introduction|| |
There is growing awareness that research in primary care is essential to inform practice and to develop better health systems and policies. Compared to other clinical disciplines, however, primary care has produced significantly less published research. Primary care physicians need to be an integral part of the research initiative; consequently, the right questions will be asked, the results will be used in practice, and a scholarly evidence-based approach to primary care will become the norm.
Participation in research can increase clinicians' professional confidence and self-esteem, and it may also improve the status of primary care as a career choice. Involving these trainees in research motivates them to pursue further research training. Research during residency training has become an integral part of medical education in many countries in the early 21st century and has influenced the subsequent performance of physicians. Participation in clinical research during training also yields positive results in the development of essential skills, including critical analysis and leadership, and can determine whether the professional pursue an academic or research career. However, the focus on research has been sub-optimal concerning residency training programs., Further, little research concerning primary care has been produced by physicians in many countries, especially by physicians working in institutions in the developing world often with limited resources.
Family practice is diversified, and various issues with a weak evidence base need to be studied, including clinical conditions, patient behavior, and healthcare organization. Family physicians conduct primary care research in many contexts that are used to improve practice and policy: methodology, clinical studies, health services, health systems, and educational. Family physicians can also easily recruit patients because of the trusting relationships they have established with patients over time.
Family medicine is a relatively new initiative in the eastern Mediterranean region. Saudi Arabia was one of the first countries among Arabian Gulf countries to reform its healthcare system following the World Health Organization's (WHO 1978) Alma-Ata declaration, which established the goal of “Health for all” in 2000. Later that year, the Arab League established the Arab Board of Health specialties, which later added the Family Medicine Scientific Council to its structure to begin certifying family medicine physicians. Then, in 1982, two Saudi universities launched postgraduate training in family medicine in collaboration with international institutions. A decade later, Saudi Arabia established the Saudi Commission for Health Specialties (SCFHS) with the Family Medicine Scientific Council as one of its essential disciplines. This 4-year program certifies family medicine physicians.
Since research is crucial to the advancement of the medical field, the SCFHS mandates that all family medicine residents actively participate in some form of scholarly activity, such as original research, comprehensive case reports, or reviewing assigned clinical and research topics. Furthermore, the residents must attend a mandatory research course for 6 weeks during their 2nd year of training. Then, they spend the rest of their 2nd year and the 3rd year conducting the research and writing the final report for the defense examination. Some residents submit their work for publication in peer-reviewed journals. Understandably, patient care typically takes priority over research; therefore, many physicians have difficulty initiating and publishing scholarly work.,,
While many previous reports focused on family physicians who are successful academic researchers, little is known about nonacademic family physician researchers, especially in Saudi Arabia. Specifically, there are few data regarding the motivations, scope, publication experiences, and barriers faced by successful community-based researchers. What was their attitude toward publication? What percentage of their work was published in peer-reviewed journals? Did they continue to publish after their training was complete? What were the reasons for not submitting their work for publication? What resources were available to them and what obstacles did they face? This study aims to examine the topics covered and the type, scope, and methodology used in family physicians' research projects. In addition, this study explores the determinants and barriers to publishing that affect family physicians' publication behavior.
| Methods|| |
This cross-sectional study reviewed the research projects and publications of two groups of family physicians after they obtained their family medicine certification in 2012 and 2013. Participants were followed for 5 years. The authors of the present study collected the E-mails of all family medicine residents in Saudi Arabia who completed their training in 2012 (93 residents) and 2013 (116 residents). The researchers invited all of these family physicians to complete a predesigned, self-administered electronic questionnaire with a short description of the study aim and instructions on how to complete and submit it online. Participation was voluntary. The authors sent a maximum of five friendly reminders to encourage physicians to participate.
The questionnaire consisted of the following: training center affiliation, physicians' name and sex, the year the residency training was completed, titles of their projects during training, and whether they published their projects in a peer-reviewed journal. In addition, participants were asked to provide information concerning the study design, statistical analyses, setting, research area, hypotheses, support, and the name of the target journal. Furthermore, participants were asked about their attitude toward research, research uses, obstacles and barriers faced, and suggestions to improve the research practice.
Physicians' scientific publication history was followed for 5 years, which were verified through PubMed, Google Scholar, the Saudi Digital Library, and Google by searching the physicians' names and project titles. Three mentors reviewed the questionnaire for further improvement and validation. Questions were primarily closed-ended (yes, no, and do not know responses). The study was piloted with 20 family physicians before distribution. The physicians who participated in the pilot provided comments concerning clarity, comprehension, and the time required to complete the questionnaire. Pilot questionnaires were excluded from the final analyses. The final self-administered questionnaire consisted of 31 questions and took approximately 10–15 min to complete.
Data were analyzed using IBM SPSS Statistics for Windows, (Version 21.0. Armonk, NY: IBM Corp., The USA). Descriptive statistics included frequencies and percentages. Bivariate analyses were employed in comparing responses between those who published and those who did not. Numerical variables were reported as means ± standard deviations. Chi-square tests were used to assess the association between different categorical variables. P < 0.05 was considered statistically significant. Open-ended comments about research and publication activities were reviewed for coding.
This project was approved by the Institutional Review Board of the College of Medicine, King Saud University.
| Results|| |
Of the invited 209 residents who completed their SCFHS training in family medicine, 157 (75.1%) submitted questionnaires that detailed their research experiences. Of them, 76 (48.4%) published an article in a peer-reviewed journal (38.6% in 2012 and 56.3% in 2013).
In 2013, physicians who had secured funding for their project published significantly more often than did their counterparts. Further, although female physicians published more often than did their male counterparts (50.0% vs. 47.6%), these differences were not statistically significant [Table 1]. Over the 5-year follow-up period, participants managed to publish an additional 93 articles in peer-reviewed journals. The impact factors of these journals were as follows: not ascertained (89.2%) (because we did not find any impact factor figure reported in the journals website), <1 (6.4%), or 2–3 (4.5%). Only 10.8% were published in Web of science institute for scientific information ranked journals.
The mean number of publications was statistically higher among the physicians who completed their training in 2013 than among those who had completed their training in 2012 [Table 2]. Physicians' publication experience in the years following their training is illustrated in [Table 3]. Forty-four participants managed to publish their first paper within the first 2 years of completing their projects; however, it took 20 participants between 3 and 6 years to publish their first article.
|Table 2: Participants' characteristics by the mean number of publications (n=150)|
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|Table 3: Years elapsed before publication (the number of research publications at medical journals in the years following their training)|
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The study design and analyses of residents' projects are shown in [Figure 1] and [Table 4], respectively. Most study designs were quantitative, observational, and cross-sectional.
|Figure 1: Study types. First published articles (n = 76; 71 cross-sectional, 3 cohort, and 2 case–control studies). Follow-up publications over five years conducted by 15 family physicians (n = 77; 66 cross-sectional, 5 cohort, 1 case–control, 3 reviews, and 2 mixed-method studies)|
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Questionnaires were employed in 93% of these studies, and the analyses were nearly always simple. During the 5-year follow-up period, 15 family physicians continued to publish a total of 77 papers in peer-reviewed journals. The designs of these papers were similar to the first published group of papers out of their trainee projects. The only differences were two studies that employed either a qualitative or mixed-method design and three studies that were review articles. Regarding participants' interest in publishing in peer-reviewed journals, most said that they were not sure whether they wanted to be involved in such a scholarly activity. The perceived reasons for this lack of interest are shown in [Table 5].
|Table 5: Participants' attitude toward publication and reasons for not publishing immediately after training|
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| Discussion|| |
To the best of our knowledge, this was the first study to address the scholarly output of family physicians as evidenced by their publications after completing family medicine training and obtaining their SCFHS certificate. The authors not only addressed a previously neglected issue in family medicine practice but also attempted a comprehensive assessment of physicians' 5-year publication rate. Understanding the perceptions, attitudes, and practice of recent SCFHS graduates can shed light on some of the obstacles faced by family physicians and lead to improved research practices among future physicians. Early identification along with crucial solutions to these difficulties is essential in the efforts to produce a new generation of competent family physicians who can improve the quality of healthcare in Saudi Arabia.
In addition, the findings were consistent with those reported for other specialties such as anesthesia, pediatrics, obstetrics, and gynecology.,, The response rate was deemed acceptable for this type of the study and was similar to others.
Although most participants believed that conducting research was worthwhile and all of them completed their research projects, less than half published in peer-reviewed journals. However, the publication rate was higher than what had been previously reported in primary healthcare publications from 1983 to 2011, as 655 primary healthcare research articles during that 28-year-period were published.
The residency programs also saw an increase in family medicine trainees and research activity from 2012 to 2013. These are similar to the findings of other investigators from other countries; however, in one study, participants' publication success varied depending on the methodology, the institutional commitment, and whether the research mentor was allowed protected time to administer, teach, and evaluate all research components. Local or national organization support and previous research experience are also associated with improved outcomes through greater involvement in research and publication.
Further, research methodology workshops significantly improve participants' research-related knowledge and skills. Although our participants received research training and education, their publication rate was still lower than expected. A previous study indicated that limited research interest was mostly driven by poor research training and education.,
Nonetheless, there is a need for appropriate organization of the training process to avoid interference with the clinical and other vital responsibilities. Further, residents' participation in research was associated with higher satisfaction with residency training., Unfortunately, most participants were hesitant to publish their projects in peer-reviewed health journals.
It took an average of 2 years for most articles to be published in journals. Some waited between 3 and 5 years to produce their first paper. However, other reasons for not publishing may be attributed to the fact that some journals take at least a year to publish owing to a backlog. Furthermore, it is common that multiple journals will reject or tentatively accept but ultimately reject an article before it gets published., Commonly cited barriers included lack of funding support, unavailability of full-time mentors, and most notably, a lack of time. Scheduling conflicts were also noted as reasons in another study that examined pediatric, radiology, anesthesiology, and psychiatry residencies.
Our study participants perceived obstacle to publishing in peer-reviewed journals was the difficulty faced in attaining a professional research supervisor, which is similar to a previous finding. The overall quality of research by family physicians will undoubtedly suffer, and the rate of rejection by journals will increase if family physicians cannot afford to spend adequate time on research due to scheduling conflicts. All who were appointed to an academic department specializing in family and community medicine had published their projects, and some of them had multiple publications. This was more apparent than the publications from other Arab academic institutions (46%). This favorable finding may be attributed to greater availability of technical support and greater availability and accessibility of more training related courses and the presence of devoted full-time mentors in Saudi academic departments. Furthermore, the university setting offers opportunities for collaboration with researchers from other disciplines, which, can reinforce the legitimacy of research in family practice. Furthermore, there is an opportunity for fruitful cooperation between teaching staff who successfully publish and other nonacademic family physicians.
Concerning study design, most followed the traditional epidemiologic approaches that are most commonly used by primary care researchers. Most (93%) projects were cross-sectional studies on knowledge, attitude, and practice using questionnaires. Due to sociopsychological and environmental perspectives on primary care, it is possible both to improve the quality of primary care and to address the diverse needs and concerns of clients using a mixed-method approach. Although a mixed-method research design is particularly relevant for primary care medicine worldwide,,,, the design is labor-intensive and comprises multiple stages of data collection and analysis.
The challenges of less severe clinical conditions and heterogeneous cases in primary care settings may be responsible for the scarcity of randomized controlled trials conducted by the participating family physicians. In addition, the statistical analyses used relied mainly on frequencies, percentages, means, t-tests, and Chi-square tests. This may reflect a lack of financial and technical support. All of these factors could lead to a lack of interest in publishing, rejection of a submitted manuscript, or publication in low-impact journals as reported by previous researchers.,,, Efforts to improve the quantity, quality, and speed of publication should involve more hands-on training workshops and full-time mentoring.
Further, concerning region and sex differences, the central region had the highest proportion of publications (61.8%), which may be attributed to the availability of more universities, a finding consistent with previous findings., Moreover, there was no significant sex difference in publication rate, which was consistent with the past study.
To ameliorate the challenge of publishing research, the incorporation by SCFHS of a research methods course during residency training may contribute to improved scholarly activity in the future. This is evident in a previous study by. In addition, to create a strong infrastructure, it is necessary to enhance connections to researchers in other fields, particularly in academic departments, improve training programs for future family physician researchers, develop more practice-based family practice research networks, and increase funding for research. Furthermore, mentoring, local or national foundational support, and previous research experience are beneficial, as reported by other researchers., Residents should also be provided dedicated time to attend their courses, attend workshops, and conduct their research. Granting secondment to research intuitions or sabbatical may improve the situation.
One-way to circumvent the lack of professional supervisors and scheduling conflict is to prepare educational materials for physicians in training and in service to view online at their leisure. This formal online program may appreciably enhance residents' interest in research-related activity and has resulted in a significant increase in resident-authored research papers, as reported in a previous study. The details of how these systems and programs constitute or otherwise stand in relation to each other may be delineated after discussion between the program directors, residents, and physicians.
More emphasis should be given to providing practical training in statistics and scientific writing. Other ideas that might help those who are interested in publishing may be formulating research networking groups. It is necessary to institute national and international research networks commitment with appropriate resources and training and scientifically sound collaborative research projects, as already implemented in countries such as the USA, the UK, and Switzerland.,,,, These networks should ideally be attached to universities and should provide scientific input. Networks may open the way to fruitful collaboration among researchers with the same interest, allowing them to complement each other both technically and resourcefully.
The WHO and the World Organization of Family Doctors have the potential to become powerful advocates in strengthening primary care research and dissemination. In-depth investigation of clinical, preventive and promotive, psychosocial, health system, and operation aspects of primary care help decision-makers improve health costs effectively. Particularly, Saudi Arabia is now at the stage of great national transformation and health reform as part of the Saudi Vision 2030.
There is a need for serious negotiation with leading funding agencies such as King Abdul-Aziz City for Science and Technology, the Ministry of Health, the King Salman Centre for Disabled Children, universities, and other private agencies to provide financial support for research. The academic departments of family and community medicine at participating universities can help with the technical aspects of research. A list of research priorities locally and nationally should be prepared and disseminated to training centers. Furthermore, offering remuneration to investigators may be one way of providing incentives to conduct research.
The present study focused only on published research in peer-reviewed journals. It did not consider abstracts or poster, or conference presentations. Further, the opinions of patients and professionals from other disciplines were not collected; however, these could provide additional insight into the feasibility of conducting research in primary care settings and collaboration of family physicians with their peers. Finally, nonresponders' reasons for refusing participation were not gathered; therefore, there is no way to determine whether they hold significantly different points of view.
| Conclusion|| |
The attitudes of family physicians toward research and publication were mainly positive; however, these were not reflected in their publication rate. The key barriers they faced comprised a lack of time, financial support, and professional mentors.
Consequently, there is an urgent need to formulate a family medicine research strategy. Lastly, publication should be promoted with continued education concerning research methodology, analysis, and writing support, and incentives such as professional mentors, financial support, and awards.
The researchers would like to thank the participating family physicians for allowing this study to take place. They are grateful to the Deanship of Scientific Research at King Saud University for supporting this study through the Vice Deanship of Scientific Research Chairs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]