1.Introduction

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The scientific activities of universities and research centres are assessed by the quantity and quality of publications [1]. The evaluation of biomedical publications from Arab countries has shown that its quantity and quality lag far behind the rest of the world[2] although it increased in the last decade such as in Saudi Arabia [3]. The contribution of the Arab countries to PubMed is only 0.6%. Saudi Arabia and Egypt publish almost half of them [4]. According to UNESCO 2005, USA and Europe share is two third in scientific publications while all developing countries together make 11% [5].Only very few publications addressed this issue and tried to understand the reasons related to it.

The published studies assessing biomedical research output of Arab countries have been mainly quantitative [[6],[7]]. The cause behind this poor performance is unclear. The best populations who can explain the possible reasons for the deficient deliveries of biomedical publication are the health care professionals themselves.
Saudi Arabia is one of the largest Middle Eastern Countries attracting many international health care professionals who have been educated and trained abroad. This makes them along with the Saudi colleagues, an adequate sample to give an appropriate answer to our questions in regard to the causes behind this deficiency. Additionally, they may have an opinion as to how to improve this situation.

This study attempts to explore the possible factors for the production of biomedical publication. Furthermore, it also tries to come up with some possible improvement to enhance publication.

2. Methods And Subjects

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This research is an exploratory survey of physicians attending 4-days Cardiology Conference of Arab countries in Saudi Arabia 2014. From 180 questionnaires distributed to the physicians, 123 were returned and 8 were excluded for being incomplete. Attendees of this meeting included cardiac surgeons, adult and paediatric cardiologists, internal medicine physicians, general paediatricians, clinical pharmacists, intensive care physicians, and anaesthetists.

Participating physicians were assured that the information they provide is confidential and only used for scientific research. The questionnaire was anonymous. The participants were given the option to refuse to fill the questionnaire. Returning the filled self-administered questionnaire is considered their consent.

A questionnaire with a total of three parts was designed.

2.1. The first part
included the demographic data, country of undergraduate medical education, the country of postgraduate medical training, the highest educational degree reached, their clinical speciality and its duration, and the nature of their current position. Responders who have more than one job category were asked to rank them according degree of involvement. Additionally, it included whether the participant was trained and involved in any scientific research or publications.

2.2. The second part
focused on questions about their opinion for the reasons behind such low production of research in Arab Countries. The responder was given 13 questions which focused on three main options:

• the reason is due to poor undergraduate education and curriculum,
• the reason is due to the institute in regards to lack of protected time, unavailability of databases or registries, lack of supervision and lack of economic support,
• the reason is personal in regard to unwillingness or other personal commitments,
• a general reason in regard to decision maker do not consider research importance.
The responders were allowed to select more than one reason.

2.3. The third part
addresses the opinion of the participants about their ideas how to best improve this situation. The responder was given six questions which are mainly focused on improvement of the institutional factors which are pointed in the second part. At the end of both second and third part the responders had the chance to describe in their own words the reasons behind low biomedical publication productivity and the methods to improve that.The Institutional Review Board (IRB) at King Fahd Medical City (KFMC) approved this research.

3. Data Processing

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The questionnaire was tested by Cronbach alpha test to evaluate the reliability of its answers. For this reason it was delivered initially to a pilot group of 20 physicians. The result of this test showed an alpha value of 0.7, which indicated an acceptable reliability.

SPSS version 17 was used for the statistical analysis. Publishing physicians and those not publishing were compared. The Chi-square and t-test were used to determine the statistical significance of association between variables. In addition logistic regression was used to predict the most important factors for publishing / not publishing. The p-value ≤ 0.05 was considered significant.

4. Aim Of The Study

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The aim of this study was to explore some factors enabling/ disabling production of biomedical publication of physicians and their suggestions to improve publication.

5. Results

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Response rate was 68% (123/180). Further incomplete responses (n=8) were excluded. A total of 115 responses (25 % females, 75 % males) were analysed. The current job of physicians shows that over 80% are involved in patient care, 10 % are researchers, 5 % in education, and 5 % in administration.A total of 46.9 % had publications, while 53.1% did neverpublish.60% were doing research and 40 % not more male physicians publishing researches than female physicians. Two third of the interviewed physicians are pediatricians (39%) or internists (36%). Publishing physicians are significantly older than not publishing physicians.

The undergraduate education was 74% in Arab countries, 9.6 % in Africa, 8.7% in Pakistan / India and6 % in Europe or North America. The highest degree of education was 19% Arab Board, 20 % PhD, 13 % had Master Degree and the rest had baccalaureate or local degree.

Table 2 demonstrates that 60.8% of physicians had postgraduate education in Arab countries, 9.5% in USA, and 13.9% in Europe. Physicians with postgraduate studies in USA published more than others (91.7%), followed by India/Pakistan (50%), West Europe (46%), Middle East Arab countries (40%), East Europe and Africa (33%).Two third of physicians attended research method courses.Significantly more of those publishing (77.8%) attended a research method course than those not publishing, and significantly more of them (85.2%) are doing research at present.

Table 3 illustrates that there is no difference between publishing and not publishing physicians regarding the work environment except that significantly more of publishing physicians mentioned more ‗lack of economic support to research‘ (64.8%) than not publishing.No difference were found between publishing and not publishing physicians regarding their personal limitations or commitments such as time, social, religious or political commitment. 48.7% of all physicians mentioned lack of time for research as limitation. Social, religious or political commitment were for 92- 97% of physicians of no importance.

Table 4 presents the suggestions regarding improvement of research. 75% of physicians asked for medical education reform. Economic support and encouragement of research are significantly more mentioned by publishing than not publishing physicians.
Table 5 shows the most important variables contributing to publishing such as being a male physician, being older, having attended a research course, social commitment. In addition, political and institutional factors ―decision makers are not interested in research‖, ―no time allocation for research‖, or ―no mentor for research‖ affect publication. Characteristics of physician and personal factors affect publishing more than policy / institutional factors.

6. Discussion

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Research contributes to the knowledge, culture and development of the society and solves its problems. Biomedical research has an impact on the health and clinical outcome [8]. Factors behind lagging of Arab countries physicians in producing biomedical publication are diverse on national, institutional as well as on personal level. An important factor mentioned by physicians for impeding publishing was ―decision makers do not consider research important‖. The political commitment to research and development may exist in the Arab world but does not reflect in the gross domestic expenditure on it, as World Bank data reflect that 0.04 – 0.7% in 2014 is spent from different Arab nations compared to the total World of over 2.08%[9].

7. Factors Related To Characteristics Of Physicians

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Female physicians in this study publish significantly less than male physician. This is worldwide the situation, where less than 30% are women authors and over 70% are men authors in science domains. Is it due to disparity in hiring, earning, funding of research [10],[11] or due to their smaller numbers or to their triple roles being in addition housewives and mothers? Qualitative studies on this issue are needed as studies found are bibliometric [12]. However, authors‘ names are not always indicating their gender, as there is no standardized way for writing the authors‘ name. Some names are common for both genders. Foreign names are sometimes difficult to reveal their gender.

Physicians seem to develop their interest in research and publishing a little bit later during their career. As this study revealed, the older the physicians are and the longer the duration of graduation, the higher the probability of publishing. Assumingly young physicians want to gain experience first in practicing medicine. On personal level lack of time for research seem to be an important factor.

8. Attendance Of Research Methods Course

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One of the most important factors for publishing is the attendance of research methods course initiating the interest of physician in research and publishing. Probably there is recognition that these courses are enhancing research as Kuwait University initiated an extracurricular research method course for senior medical students [13] and Faculty of Medicine for Girls Al Azhar University did it for young staff members [14].

Physicians with postgraduate studies in North America are apparently more trained in research and publishing than those studying in other countries.

9. Institutional Factors

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Institutions who built a culture of research have to develop their policy and strategy to improve research activities. It includes productive environment for research, training, funding, mentoring and continuing education [15]. In this study physicians identified institutional factors such as ―no time allocated for research at work‖, ―lack of economic support for research‖ and ―lack of mentoring of research‖ contributes most to lag of research and publishing.

10. Suggestions For Improvement Of Research

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Medical education is changing all over the world since last century [16, 17]. The majority of physicians suggest the reform of the under graduate and postgraduate curricula and research method courses which is in process in most Arab countries. In addition Jenkins and Healey suggest the integration of research in teaching [18]. The physicians propose funding of research and assigning time for it during work which is also pointed to in the Hanover Research [15].

11. Conclusion

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Older male physicians publish more biomedical research than younger and females. Lack of time is an important hindering factor. Having attended a research method course encourages undertaking research and publication. Lack of institutional and policy supports such as no funds, mentoring, time and data base are limiting factors. Most physicians suggest the reform of under and postgraduate medical education.

12. Recommendations

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There are different levels to encourage research: governmental, schools, university, institutions or hospitals in this case. The government has to acknowledge, that without encouraging research in general, there is no real advancement. Elias Zerhouni, former 15th NIH director (between 2002 and 2008), said that ―Societies have the duty of accumulating knowledge‖, ―Research and science go to the societies which welcome them most.‖ (personal communication).

According to our impression this might include changing the curricula at school to include scientific thinking as well teaching research methods and basic statistics. At medical schools the knowledge of scientific work and statistics needs to be increased. Workshops on how to do research should be a must in every university curricula. Finally, hospitals should work on building a culture of research. As suggested by the Hanover Research [15], a culture of research provides a supportive context in which research is uniformly expected, discussed, produced, and valued. In May 2014, the organization published an essay entitled -Building a culture of research: recommended practices.‖Intellectual honesty, Accurate assignment of credit, Fairness in peer review, collegiality in scientific interactions, transparency in conflicts of interest, protection of human subjects in the conduct of research,humane care and treatment of animals, adherence to mutual responsibility within and between research teams.

13. Limitation Of The Study

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Since this study was done in a conference of cardiology not all specializations were present. Only two third of attendee returned their questionnaires the reasons are not known why the other third did not participate in this study. It is possible that the percentage of publishing attendees is higher than other physicians who are not interested to attend conferences.

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