Contribution of Arab countries to the global wealth of biomedical research production has been subpar (15), even when compared to other middle eastern countries such as Iran and Turkey (16). Furthermore, medical research production in Syria has been amongst the lowest of the Arab world, including when comparing to its neighbor Lebanon (10, 15, 16). Starting in 2011, Syria has also had a decade-long war that severely crippled its healthcare system. This created an unfortunate, yet an important opportunity and need, for research in healthcare (17). Many facets now require further study and analysis, including the effects of lack of medicines and healthcare services accessibility, the spread of endemic diseases, and the war-related injuries. One might reasonably argue for a global duty to share expertise about these aspects (18), especially that Syria has seen the most severe humanitarian crisis since world war two (19). Under such conditions, although it is crucial to equip post-graduate students with updated clinical knowledge and skills, it is equally important to empower them with scientific research skills to enhance research production in a way that improves the healthcare services (14, 20, 21). It is also indispensable to assess the attitude of resident doctors towards research in order to suggest solutions that meet their true needs.
Participants in this survey study reported high positive attitudes towards medical research similarly to what was reported in Saudi Arabia (22), one of the leading Arab countries in medical research conduct (15, 16). These attitudes were also higher in comparison to the attitudes of medical students at Damascus University, which were captured in 2018 using the same tool of measurement (13). However, this contrasted with two studies from Iran and Pakistan that reported postgraduates to have had lower attitudes towards research than undergraduates (23, 24). The reasons for that in the Syrian sample might have been that postgraduates were in daily contact with the uncertainties in disease management, the limitations of relevant guidelines, along with the limited resources as in Syria especially during the crisis (25). The results reflected the participants’ willingness to contribute to research even while suffering from the devastating consequences of this war, and the main motivations for that were to relay evidence-based knowledge and to develop a flourishing academic career.
These attitudes were faced with a wide variety of barriers, the most important of which was the absence of adequate training of research methodology in higher education. Similarly, the latter reason had also been singled out as the main barrier in a sample of nearly 200 medical residents in Saudi Arabia (22). It is worth noting that all the included programs had at least one module for research methodology during the first, second or third year of higher medical education. However, these modules were deemed ineffective in equipping students with the necessary tools. The unavailability of research mentors was another important obstacle reported by our studied group of students. This finding was in line with several other studies even in the most productive countries in medical research in the area such as Saudi Arabia and Iran (22, 24). However, that did not clearly reflect the true importance of this limitation, because lack of time, funding and reward as well as stress were factors of more importance than mentors’ unavailability to the Saudi, Pakistani and Iranian participants (22, 24, 26). On the contrary, this study showed that Syrian postgraduates were in need of mentors’ support more than being affected by these aforementioned detrimental factors. For example, Khan et al. reported that 65.2% of Pakistani postgraduate medical trainees thought they could plan and conduct research without supervision, and only 11% of participants considered the unavailability of mentors as a hindrance (26). However, that was different to the case in Syria, because the knowledge, experience, and confidence of this Pakistani sample regarding research seemed to have been much higher than the ones reported by our participants.
As reported by the current sample, lack of time remained an important limitation to medical research in Syria, especially during the current war (27), and this limitation was specifically more significant to resident physicians worldwide (28–30). The participants seemed to focus more on the studies that required less methodological knowledge, less support by mentors, and the ones that could be conducted without funding, such as case reports, followed by cross-sectional studies. However, the number of published case reports remained modest (31, 32), and these studies were less likely to fulfill the unmet research needs of the Syrian healthcare system.
Research contribution by postgraduates of the different Syrian universities was similar in the current study, which was a remarkable improvement from the article published in 2011 which had reported that more than half of the Syrian publications had originated from Damascus University (10). This finding was supported as well by a recent review of the published articles from the different Syrian cities (17). This might have been due to a higher rate of mentors leaving the country from the capital, or due to a safer environment in Tishreen University in Latakia. Furthermore, higher-education students at Tishreen University reported higher rates of contributing to and publishing medical research in comparison to the other two largest universities, Damascus and Aleppo, although this difference was not statistically significant.
In the light of the findings of this study, institutional and individual efforts should aim to mitigate these barriers and boost the positive attitudes towards research and publication productivity among post-graduate students. Syrian institutions should implement more in-house workshops based on trusted educational sources. They should also follow an approach that fits the local limited resources. For instance, a remote-site for the Introduction to the Principles and Practice of Clinical Research (IPPCR) course, presented by the U.S. National Institutes of Health (NIH) (33), was established in Syria since 2015 and more than four annual workshops based on this course have been delivered so far (14, 34). Online workshops, on the other hand, can provide a more affordable, widely accessible, and flexible option that still leads to comparable results (14, 20, 35–37). These educational events should cover all aspects of research methodology, academic writing, and biomedical statistics. These workshops should be recorded and published afterwards for self-paced learning, which proved to be the most effective methods in the current study.
Other methods that can reduce the wasted time during research conduct might also be beneficial, such as electronic medical records which facilitate health data acquisition and processing especially in retrospective studies (14). Relaxing the restrictions and requirements for master theses might also facilitate publication, such as allowing students to conduct bibliographical studies such as systematic reviews and meta-epidemiological studies which can be done even in hospitals with low flow of patients and still produce high-quality evidence.
Another institutional suggestion is to build an online platform that archives all Master and PhD research projects, making them available for all national and international researchers. This platform can allow national collaboration between post-graduate students in different universities and different specialties, as well as between them and other healthcare researchers nationally and internationally. In addition to that, organizing a national annual conference for published master theses in peer-reviewed journals to be presented to younger students, which would spark excitement and encourage scholarly activity (38). For better applicability, this can be supplemented by publishing an Arabic concise guide targeting mentors and post-graduate students summarizing the basics of research methodology, academic writing, and medical statistics. These training and partnership attempts in addition to leadership skills lied at the heart of the recently published framework, which aimed at strengthening health research capacities in the Middle East and North Africa region (21).
The numbers of mentors in Syria dropped significantly during the years of the conflict (7, 8, 39). However, they still hold a crucial responsibility in the process of improving research conduct among their mentees. Their expertise that accumulated over the years of war might have uncovered to them many crisis-related possible research topics that are of high priority and need to be investigated and reported. Mentors’ active encouragement is also one of the most established associations with higher research output in this study and in others (22, 24). However, this encouragement needs to be as practical as possible, at least by frequent meetings with students and critical revisions of each phase of the projects. Another suggestion to overcome this lack of supervisors in Syria is to allow long-distance mentoring by experts in other countries (40).
Residents also have their share of the responsibility, the first step of which may be to collaborate with colleagues to provide scientific support, conduct nation-wide studies, and reduce efforts duplication. These collaborations can take place between colleagues from the same specialty in two different institutions or across disciplines to provide a more translational and multifaceted analysis of the health problems. Another advice is trying to get involved in other research studies before the time to do their master theses, because it was shown that medical students who were involved in research projects had superior research productivity after graduation (29, 41). Furthermore, cooperating between post-graduate students and medical undergraduate students who are interested in the same specialty may reduce the time burden for postgraduates and create additional opportunities for undergraduates to participate in the master thesis publication. The suggested platform for studies registration above can play a pivotal role in creating these collaborations.
The data in this survey study were collected using a self-reported online questionnaire. However, the individualized communication of the survey in small groups by the chief residents with all their respective resident groups had maximized the recruitment. Recruitment for participants in the surgery and medical education specialties was low in comparison to all other specialties who had a recruitment rate of 22% or more. This might have been caused by tighter lifestyles or lower research interest among trainees in these two disciplines. That might also explain the apparent higher attitudes and participation of those specific responders because they represented only the highly interested students without reflecting the true image of all students of surgery and medical education. However, the current study captured the opinions of nearly a quarter of the whole targeted population in all of Syria, fulfilling the goal to assess post-graduate students’ attitudes, barriers and practices in research, and to suggest fact-based solutions that could save a lot of the currently wasted efforts by pushing master theses projects towards publication.