JBJS | Misrepresentation of Research Criteria by Orthopaedic Residency Applicants*

The Journal of Bone & Joint Surgery, Volume 81, Issue 12

Articles | December 01, 1999

Misrepresentation of Research Criteria by Orthopaedic Residency Applicants*

J. ALEXANDRA DALE, M.D.†; COLLEEN M. SCHMITT, M.D., M.H.S.†; LYNN A. CROSBY, M.D.†, CHATTANOOGA, TENNESSEE

Investigation performed at the Department of Orthopaedic Surgery, Chattanooga Unit of the College of Medicine, University of Tennessee, Memphis, Chattanooga

The Journal of Bone & Joint Surgery. 1999; 81:1679-81

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Abstract

Background: Previous studies have shown that applicants for postgraduate training may misrepresent research citations. We evaluated the research citations that were identified in a review of the Publications and Work and Research sections from the Electronic Residency Application Service (ERAS) data for all applicants to our orthopaedic residency program for the 1998 to 1999 academic year.Methods: The citations were searched for on Medline. We initially used the name of the first author, then the name of the applicant, the name of the journal, the volume number, the issue number, and the page numbers. When a journal was not listed in Medline, an interlibrary search was instituted with use of the same format. When no match was made for any category, the citation was defined as misrepresented. Point estimates are reported as percentages.Results: Publications were listed on sixty-four (30.0 percent) of 213 applications. One hundred and thirty-eight publications were cited; there were fifteen citations (10.9 percent) to book chapters, twenty-six (18.8 percent) to journals not listed in Ulrich's International Periodicals Directory, and twenty-one (15.2 percent) to articles listed as in press, in print, or submitted for publication. Seventy-six articles that had been cited as appearing in journals listed in Ulrich's Directory were checked and verified. Fourteen (18 percent) of these seventy-six publications were misrepresented. Misrepresentations included citations of nonexistent articles in actual journals and nonauthorship of existing articles.Conclusions: We concluded that publications listed on postgraduate applications should be scrutinized carefully. Copies of cited publications should be required by residency programs before applications are considered complete. The importance of professionalism needs to be emphasized in the curricula of medical schools. Residency training programs should develop guidelines regarding misrepresentation.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Research experience and publication of original manuscripts are perceived by applicants and training programs as factors that may enhance a candidate's potential. Most candidates for residency positions in specialty fields have participated in some type of research. With the recent reduction in the number of residency positions available, candidates may seek a competitive advantage. Previous studies have suggested that applicants for postgraduate training may misrepresent research citations in order to enhance their application^2-4,7. Gurudevan and Mower examined applications to an emergency-medicine residency program and found an alarming level of misrepresentation: twenty-three (20.4 percent) of 113 applicants who cited publications had misrepresented citations³.

There has been no documentation of similar misrepresentation by applicants to orthopaedic residency programs, to our knowledge. Given the competitive nature of the residency application process and the recent reduction in the number of orthopaedic positions available, we hypothesized that misrepresentation of published research exists. The purpose of our study was to evaluate the prevalence of such misrepresentation among recent applicants to the Orthopaedic Residency Training Program at the Chattanooga Unit of the University of Tennessee College of Medicine.

*No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Chattanooga Unit of the College of Medicine, University of Tennessee, Memphis, 975 East Third Street, Hospital Box 260, Chattanooga, Tennessee 37403.

*No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Chattanooga Unit of the College of Medicine, University of Tennessee, Memphis, 975 East Third Street, Hospital Box 260, Chattanooga, Tennessee 37403.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Two hundred and thirteen applications were submitted for the two positions available for the 1998 to 1999 academic year. Research citations were extracted from the Publications and Work and Research sections of each application. We defined a research citation as an article or abstract that had been published in a serial listed in Ulrich's International Periodicals Directory⁶. This directory contains information on 165,000 international serials and is often considered to be the definitive reference on the existence of a journal⁶. We excluded book chapters and citations that were not listed in Ulrich's Directory from our study because we were unable to verify authorship. Articles that were listed as in press, in print, or submitted for publication were also excluded because of the limited amount of time between the submission of the applications and our review.

We used a standardized format to verify the research citations. A Medline search was generated. We searched sequentially with the following keywords or texts: the name of the first author, the name of the applicant, the name of the journal, the volume number, the issue number, and, lastly, the page numbers as listed on the applications. If no match was found, an interlibrary search was instituted with use of the same format. Finally, a second review, for spelling or other abstraction errors, was undertaken, and the process was repeated. We required visual review of the citation for verification. We considered a citation to be a misrepresentation when no match was found in any category. Our results are reported as proportions (percentages).

Results

Introduction | Materials and Methods | Results | Discussion | References

For the 1998 to 1999 academic year, there were 213 applicants to our residency program. Publications were reported by sixty-four (30.0 percent) of the applicants. The number of publications ranged from one to twelve per applicant. One hundred and thirty-eight publications were cited. These included fifteen book chapters (10.9 percent), twenty-six articles in journals that were not listed in Ulrich's Directory⁶ (18.8 percent), and twenty-one articles listed as in press, in print, or submitted for publication (15.2 percent). Seventy-six publications listed by forty-nine (23.0 percent) of the applicants met the criteria of a research citation. We were able to check and verify all seventy-six (100 percent) of these documents.

Fourteen (18 percent) of the seventy-six citations were considered misrepresentations, with eleven (17 percent) of the sixty-four applicants responsible for inaccurate bibliographies.

Two types of misrepresentation were detected: nonauthorship of existing articles and authorship of nonexistent articles.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

A careful review of the credentials of our applicants showed that misrepresentation of research publications extends to applicants to orthopaedic residency programs. Unfortunately, this finding was not completely unexpected. Misrepresentation of credentials and qualifications in training programs and physician employment applications has been documented^2-4,7. Sekas and Hutson reported that sixteen (30 percent) of fifty-three applicants to a gastroenterology fellowship submitted an inaccurate bibliography⁷. However, those authors used an expanded definition of misrepresentation that included articles listed as being in press that were not published within eighteen months after submission of the application and articles from journals that were not listed in Ulrich's Directory⁶. In light of their format, the percentage of misrepresentation might have been exaggerated. This discrepancy could also be explained by inaction by the applicant or his or her collaborators or by inefficiency of the publisher.

A presentation at the 1998 meeting of the American Academy of Orthopaedic Surgeons documented an 8 percent prevalence of misrepresentation (seven applicants) among eighty-eight applicants to hand fellowships, with no difference compared with the percentages for applicants to sports medicine or spine fellowships⁵. In a review of residency applications to Vanderbilt University, the authors of a study published in the Journal of the American Academy of Dermatology found considerably less misrepresentation than was found in previous reports and concluded that the inaccuracy was secondary to inexperience, not fraudulent activity². We believe that this is unlikely, given the high educational level of the applicants.

Any report of misrepresentation is a troubling commentary on the professionalism of postgraduate applicants⁴. This is an ethical problem that should be stressed in both medical schools and residency educational programs. The American Academy of Orthopaedic Surgeons has addressed many of these ethical concerns in the Guide to the Ethical Practice of Orthopaedic Surgery¹.

Applicants may falsely exaggerate their research experience to increase the likelihood of obtaining a residency position. Clerical error may be a factor, but this is unlikely given the stringent verification format that we used in our study. Applicants may erroneously list publications based on a research project in which they participated, and they may not understand that this is not equivalent to authorship. However, we believe that this is also unlikely given the high educational level of the applicants. The probability of detecting misrepresentations is small because of the difficulty in the verification process. Some of the confounding factors noted were limited office staff and an inability to locate obscure journals and to cross-reference abstracts.

In a review of our study protocol and results, several concerns arose. The study focused solely on research publications. However, postgraduate training programs also use many other credentials when evaluating applicants. Whether misrepresentation is prevalent in the context of academic awards or letters of recommendation remains to be evaluated. We had a small study group, as we reviewed only one year's applicants to a single institution. Our results cannot be generalized to all other training programs. Nonetheless, our study serves to further verify a growing problem in the medical community. Although 17 percent (eleven) of the sixty-four applicants misrepresented their publication record, the actual frequency of misrepresentation is much lower (5.2 percent) when the total group of 213 applicants, including those who did not cite any publications, is used as the denominator.

We concluded that publications listed on postgraduate applications should be scrutinized carefully. However, documentation of fraudulent bibliographies has not to date affected the prevalence of misrepresentation⁴. It is reasonable to ask what can be done to ensure that listings of abstracts and articles are valid. Unless curtailed, misrepresentation constitutes a serious threat to the integrity of academic medicine. We believe that the American Board of Internal Medicine is correct in stating that misrepresentation has the potential to harm patients, to destroy the ethical principles of our profession, and to undermine the public's trust in physicians³.

Through education, detection, and correction, training programs should be able to decrease the amount of misrepresentation. The importance of professionalism needs to be emphasized in medical school curricula and in residency training. It should not be assumed that trainees fully understand what constitutes professional behavior. The seriousness of misrepresentation and the potential consequences should be reinforced to individuals at all levels of training, including academic faculty and practicing physicians.

The verification process needs to be simplified. Copies of cited publications should be required by residency and fellowship programs before applications are considered complete. Articles listed as in press should be verified with letters of acceptance by the specific journals.

Training programs must develop policies regarding misrepresentation. To whom fraudulent activity should be reported and what action should subsequently be taken are questions that still must be answered. Kimball recommended confronting the applicant, along with notifying his or her medical school, the individuals who wrote letters of recommendation, and the specialty board⁴. We believe that there should be a consensus among residency and fellowship programs on these issues. The Guide to the Ethical Practice of Orthopaedic Surgery¹ should serve as a guide in defining the essentials of honorable behavior. Misrepresentation is a real concern for orthopaedic residency programs and others and, if discovered, it must be handled in a manner that leaves no doubt as to our personal and collective standard of integrity.

References

Introduction | Materials and Methods | Results | Discussion | References

American Academy of Orthopaedic Surgeons, Committee on Ethics 1996-98: Guide to the Ethical Practice of Orthopaedic Surgery. Ed. 3. Rosemont, Illinois, American Academy of Orthopaedic Surgeons,1998.

Boyd, A. S.; Hook, M.; and King, L. E., Jr.: An evaluation of the accuracy of residency applicants' curricula vitae: are the claims of publications erroneous?. J. Am. Acad. Dermatol.,35: 606-608, 1996.35606 1996 [PubMed]

Gurudevan, S. V., and Mower, W. R.: Misrepresentation of research publications among emergency medicine residency applicants. Ann. Emerg. Med.,27: 327-330, 1996.27327 1996 [PubMed]

Kimball, H. R.: Credentials misrepresentation: another challenge to professionalism [editorial]. Ann. Intern. Med.,123: 58-59, 1995.12358 1995 [PubMed]

Patel, M. V.; Pradhan, B.; and Meals, R. A.: Misrepresentation of research publications among orthopaedic hand surgery fellowship applicants. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, Louisiana, March 21, 1998.

Salk, J. [editor]: Ulrich's International Periodicals Directory. Ed. 36. New Providence, New Jersey, R. R. Bowker, 1998.

Sekas, G., and Hutson, W. R.: Misrepresentation of academic accomplishments by applicants for gastroenterology fellowships. Ann. Intern. Med.,123: 38-41, 1995.12338 1995 [PubMed]

Topics

American Academy of Orthopaedic Surgeons, Committee on Ethics 1996-98: Guide to the Ethical Practice of Orthopaedic Surgery. Ed. 3. Rosemont, Illinois, American Academy of Orthopaedic Surgeons,1998.

Gurudevan, S. V., and Mower, W. R.: Misrepresentation of research publications among emergency medicine residency applicants. Ann. Emerg. Med.,27: 327-330, 1996.27327 1996 [PubMed]

Kimball, H. R.: Credentials misrepresentation: another challenge to professionalism [editorial]. Ann. Intern. Med.,123: 58-59, 1995.12358 1995 [PubMed]

Salk, J. [editor]: Ulrich's International Periodicals Directory. Ed. 36. New Providence, New Jersey, R. R. Bowker, 1998.

Sekas, G., and Hutson, W. R.: Misrepresentation of academic accomplishments by applicants for gastroenterology fellowships. Ann. Intern. Med.,123: 38-41, 1995.12338 1995 [PubMed]

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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J. ALEXANDRA DALE, COLLEEN M. SCHMITT, LYNN A. CROSBY; Misrepresentation of Research Criteria by Orthopaedic Residency Applicants*. The Journal of Bone & Joint Surgery. 1999 Dec;81(12):1679-81.

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