Is it time for integrated academic pathways in SET training?

Patients benefit from receiving care in hospitals with a strong engagement in clinical research. Some of these benefits result from institutional factors such as hospital volume and resources, but the academic competencies of surgical teams play a significant role in high quality patient care.1, 2 Surgeons with doctorate degrees are more likely to publish and obtain research grants throughout their career, and units they work in report higher rates of trainee research success and satisfaction, improved patient outcomes and greater clinical guideline adherence.3 When research is fully integrated into organizational structures, health-care performance is superior to less formal research.3 Whilst not all trainees aspire for long-term academic career trajectories, it is important for surgical training programs to address the sustainability of academic pathways. Prevalent models of surgical training do not readily support simultaneous acquisition of clinical competencies alongside more focused academic training and higher research degrees. In Australia and Aotearoa New Zealand, most surgical education and training (SET) programs allow trainees to suspend training for up to 1–2 years to complete higher research degrees. Some trainees can arrange less-than-full-time (LTFT) training positions that allow them extra time for research, but these LTFT positions can be difficult to arrange, and often are not geographically located near the trainee's research centre. Engaging in part-time research is also hindered by financial concerns, as most RACS research scholarships are only available for trainees undertaking full-time research. When re-entering clinical training after prolonged research-related absence, trainees can encounter significant challenges. The stress of returning to work, combined with loss of confidence and skills, significantly impacts trainee wellbeing and performance.4 In Nash's study of paediatric surgical trainees returning to clinical work after an interval away from training, clinical confidence needed time to be re-established: ‘I don't think your hands forget how to operate, I think it's your brain that does not have the confidence to do it’.4 Clinical and technical skills may need to be redeveloped, and time-based training programs have little flexibility to allow for this. Reestablishment of professional identity and connections with peers was also important, with many returning trainees feeling doubts about their career.4, 5 Trainees returning to academia after completing a full-time training period, typically have a considerable reduction in their research output and publications. Reduced academic output during these clinical training years hinder future competitiveness for larger research grant funding, and limit their eligibility for grants targeted towards early career researchers. Experiences from international training programs provide insights into how we can address this challenge. The integrated Clinical Academic Fellowship pathways for surgical training in the United Kingdom (UK) are well established and have been demonstrated to improve both research output and clinical skill development.6, 7 Research pathways integrated into residency training in the United States resulted in participants scoring higher on national board examinations, improved research productivity and sustained academic success.8, 9 UK ENT trainees who undertook LTFT in dedicated integrated research programs achieved more publications and academic output than non-integrated trainees in both full-time and part-time clinical positions.10 Trainees benefit from the cognitive synergy of combining clinical training and academic research relevant to their areas of expertise.11, 12 Integration of research within clinical practice, rather than prolonged intervals of full-time research, is a mechanism to provide support, link clinical skill acquisition to academic competency development, and recognize progression through training pathways.13 Trainees who participate in integrated research programs report positive work-life balance, ability to develop longitudinal research interests and sustained engagement in academic surgery.6 Despite inbuilt pathways in other surgical training systems, academic trainees continue to face challenges, including accessing protected time away from clinical duties, negative attitudes from others in the workplace, and difficulties accessing academic supervision.6 In vascular surgery, we are undertaking research to explore and codesign alternative models of training, including integrated pathways for academic development in clinical training. It is important to obtain input from trainees, supervisors and healthcare employers as to how these models can be implemented in our local context in Australia and Aotearoa. We anticipate logistical, educational and cultural challenges as these pathways are developed. Ensuring trainees are able to complete higher degrees will require strong partnerships with universities, with a clear vision for a sustainable academic surgical workforce. As we move forward in this process, we aspire for training to be flexible and adaptive to the needs of our trainees, hospitals and communities. Carina Cutmore: Conceptualization; data curation; writing – original draft; writing – review and editing. Hamid Hajian: Conceptualization; data curation; writing – review and editing. Sarah Aitken: Conceptualization; data curation; resources; supervision; writing – original draft; writing – review and editing.