Barriers to orthopedic surgery research productivity in Saudi Arabia

Abstract

BACKGROUND

Research productivity is a cornerstone of academic medicine, driving evidence-based practice, innovation, and professional advancement. In surgical specialties such as orthopedics, active research engagement is essential to improving patient outcomes and advancing clinical techniques. However, despite notable progress in Saudi Arabia’s medical research landscape, orthopedic research output remains limited and concentrated within a few institutions. Understanding the barriers that hinder orthopedic surgeons from conducting research is therefore crucial to strengthening national research capacity and aligning with Saudi Vision 2030’s goal of fostering scientific excellence.

AIM

To identify the barriers that limit research productivity among orthopedic surgeons in Saudi Arabia and explore the goals and motivations influencing their engagement in research across different subspecialties and levels of practice.

METHODS

We used a descriptive, cross-sectional, quantitative design, employing a structured online questionnaire distributed to 105 orthopedic surgeons across Saudi Arabia. The questionnaire was adapted from validated tools and reviewed for validity. Participants reported practice patterns, research activity, and barriers to productivity. Associations between variables were analyzed using univariate and multivariate methods.

RESULTS

A total of 105 orthopedic surgeons completed the survey. A statistically significant association was found between prior research experience and having served as a primary investigator within the past 5 years. Additionally, a highly significant association was found with co-authorship in the last 5 years (P < 0.001), as 52 participants (55.3%) had contributed as co-authors at least once. However, there was no significant association between prior research experience and factors such as allocated research time (P = 0.280), level of practice (P = 0.147), years in practice (P = 0.826), or the number of patients seen per week (P = 0.885). Univariate analysis revealed several barriers to research productivity: (1) Insufficient research time (71; 67.6%); (2) Lack of research assistants (57; 54.3%); (3) Inadequate research training (48; 45.7%); (4) Lack of funding (42; 40%); (5) Lack of research collaboration (39; 37.1%); (6) Lack of reward/incentive (38; 36.2%); and (7) No personal interest (20; 19.04%).

CONCLUSION

Addressing protected time, support staff, and research training may enhance orthopedic research productivity. This study highlights key institutional and educational gaps that can guide policy reforms and strengthen national orthopedic research capacity.

Key Words: Orthopedic surgery; Orthopedic research; Research productivity; Research barriers; Research training; Saudi Arabia

Core Tip: Research productivity among orthopedic surgeons in Saudi Arabia remains limited due to restricted research time, insufficient support staff, and a lack of formal research training. This cross-sectional study highlights the key barriers and motivations influencing research engagement across various practice levels. Addressing these institutional and educational gaps is essential to strengthening orthopedic research capacity and enhancing national academic output.

INTRODUCTION

Research is one of the foundational pillars of academic medicine, alongside education and clinical practice, and plays a critical role in advancing medical knowledge and patient care. Academic institutions are often evaluated using both qualitative and quantitative indicators of research performance, with publication output serving as a primary benchmark of institutional productivity and scientific credibility[1,2]. Faculty members with strong research output often benefit from professional recognition, academic promotions, and career advancement opportunities[3,4].

Motivators such as financial rewards and promotions, research interest and the potential to improve patient care often drive faculty members to participate in research[5,6]. However, studies from Saudi Arabia have reported several barriers that can prevent an institute’s faculty members from conducting scientific research, including limited research time, lack of funding, and insufficient research support, such as statistical expertise or mentorship[2,7-10]. In more advanced stages of academic careers, institutional incentives often diminish, contributing to a notable decline in research productivity[3].

Barriers to conducting research have far-reaching consequences. They limit innovation, slow the translation of evidence into clinical practice, and reduce opportunities for professional development. Over time, these challenges may also lead to reduced publication quality, hindered institutional growth, and diminished international visibility for national research.

While it continues to increase in volume, Saudi Arabia’s orthopedic research output remains limited in terms of quality and global visibility. A recent bibliometric analysis revealed that a significant portion of the output is concentrated in a few academic centers and is predominantly published in lower-impact journals[11]. These findings suggest that Saudi health sciences research is on an upward trajectory, supported by an increase in publication output and international collaborations. The country has positioned itself as a leader in medical education and research within the Arab world[10,12]. However, regional studies still report gaps in research output among specific disciplines. For instance, orthopedic research across Arab countries has been described as underdeveloped, with critics pointing to systemic institutional limitations and a lack of research culture. This underdevelopment is also reflected in bibliometric analyses, which show a persistent underrepresentation of publications from Arab countries in Q1 orthopedic journals[13,14]. Despite efforts to expand medical research across the region, orthopedic research continues to face systemic limitations and a lack of sustained research culture[12].

The primary goal of this study was to identify barriers that limit research productivity among orthopedic surgeons in Saudi Arabia and to compare how these barriers differ across subspecialties, levels of practice, and institutional settings. Additionally, we aimed to explore the goals and motivations underlying research participation to gain a comprehensive understanding of orthopedic research engagement. We chose to study orthopedic surgeons because previous bibliometric studies have identified this specialty to be underrepresented in high-impact medical research despite its clinical and economic importance, making it an ideal group for examining research barriers.

MATERIALS AND METHODS

Participants were recruited through professional networks, orthopedic surgery societies, and hospital affiliations via email and social media platforms, with informed consent obtained before participation. The study focused on licensed orthopedic surgeons actively practicing in Saudi Arabia, including consultants, specialists, fellows, and residents. It excluded undergraduates, students, and interns, as well as those not involved in clinical practice, such as retired surgeons, researchers, and professionals in administrative roles without direct patient care responsibilities.

A convenience sampling approach was used, which is suitable for exploratory cross-sectional studies where participants meet predefined inclusion criteria[8]. The sample size was calculated using a standard formula for cross-sectional studies, assuming a 95% confidence interval (CI) level, 5% margin of error, and 50% expected prevalence, which yielded a minimum of 96 participants. A total of 105 surgeons completed the survey, exceeding this requirement. Data were collected using a self-developed, structured online questionnaire designed by the research team based on an extensive review of the literature and tailored to the Saudi orthopedic context.

The questionnaire was developed after reviewing relevant studies to identify the most commonly reported barriers to research productivity. The research team then drafted and refined items to capture both institutional and individual-level barriers. The survey was divided into three sections: (1) Demographics (for example, age, sex, level of practice, subspecialty, and patient load); (2) Research activities (for example, prior research experience, allocated time, and roles as a primary or co-author investigator); and (3) Barriers and goals (for example, insufficient time, lack of funding, and motivations for engaging in research). Respondents could select one or several options for questions concerning barriers and goals, but were eventually asked to choose the single most relevant one.

Ethical considerations

This study adhered to the principles of the Belmont report-respect for persons, beneficence, and justice. Participation was voluntary, informed consent was obtained electronically, and confidentiality was maintained by anonymizing all responses. To ensure rigor, the survey underwent expert validation by two orthopedic researchers to confirm content relevance and clarity. Reliability testing during pilot administration produced a Cronbach’s alpha of 0.84, indicating good internal consistency.

Statistical analysis

Statistical analysis was conducted using Statistical Package for the Social Sciences version 21. Descriptive statistics were applied to summarize categorical variables, while associations were examined using χ² tests after verifying that assumptions were met. Both univariate and multivariate logistic regression analyses were performed to identify factors influencing research productivity while adjusting for potential confounders. A significance level of P < 0.05 was used. While efforts were made to ensure the sample was representative, recruitment through online platforms may have introduced selection bias, potentially affecting the generalizability of findings to all orthopedic surgeons in Saudi Arabia.

RESULTS

Characteristics of survey respondents

A total of 105 orthopedic surgeons completed the survey. Most respondents were males (81.9%) and held clinical roles across a range of practice levels, with academic consultants and residents being the most represented groups. Over half of the participants worked in public hospitals, while others were affiliated with university or private institutions. Pediatric orthopedics and arthroplasty were the most frequently reported subspecialties. Detailed demographic and professional characteristics are presented in Table 1.

Table 1 Characteristics of survey respondents, n (%).

Characteristics	n = 105
Sex
Male	86 (81.9)
Female	19 (18.1)
Age, mean ± SD	38.5 ± 10.22
Minimum	24
Maximum	68
Level of practice
Resident	27 (25.7)
Fellow	13 (12.4)
Specialists	12 (11.4)
Consultant (academic)	28 (26.7)
Consultant (non-academic)	25 (23.8)
Practice hospital
University hospital	50 (47.6)
Public hospital	56 (53.3)
Private hospital/clinic	28 (26.7)
Subspecialty
Pediatric orthopedic	24 (22.9)
Arthroplasty	15 (14.3)
General orthopedic	13 (12.4)
Orthopedic trauma	12 (11.4)
Sport medicine	11 (10.5)
Spine	9 (8.6)
Upper extremity	8 (7.6)
Foot and ankle	6 (5.7)
Orthopedic oncology	6 (5.7)
Deformity	7 (6.7)
Years in practice
< 5	43 (41)
5-10	21 (20)
11-20	23 (21.9)
> 20	18 (17.1)
Number of patients seen per week
1-20	25 (23.8)
21-40	25 (23.8)
41-60	30 (28.6)
> 60	25 (23.8)

Characteristics of research activities

Most respondents (89.5%) had participated in at least one previous research project. About 41% had not practiced for more than 5 years after board certification. Additionally, 41% had no dedicated research time, and 59% had not acted as primary investigators in the past year. Most research publications were case reports (72.4%), retrospective studies (63.8%), and cross-sectional studies (44.8%). Further details on research experience and publication types are presented in Table 2.

Table 2 Characteristics of respondents’ research activities, n (%).

Research activity type	n = 105
Any prior research work	94 (89.5)
Allocated research time
None	43 (41)
< 10%	43 (41)
10%-50%	19 (18.1)
Primary investigator in the last year
None	62 (59)
1-4	38 (36.2)
> 5	5(4.8)
Primary investigator in the last 5 years
None	38 (36.2)
1-4	46 (43.8)
≥ 5	11 (10.5)
> 10	10 (9.5)
Co-author in the last year
None	36 (34.3)
1-4	58 (55.2)
≥ 5	11 (10.5)
Co-author in the last 5 years
None	17 (16.2)
1-4	54 (51.4)
≥ 5	34 (32.3)
Type of prior research study participation
Randomized controlled trial	8 (7.6)
Prospective cohort	22 (21)
Retrospective	67 (63.8)
Cross-sectional	47 (44.8)
Case report	76 (72.4)
Narrative review	10 (9.5)
Systemic review	25 (23.8)

Wer identified a significant association with prior research experience, particularly in serving as a primary investigator within the past 5 years (P = 0.01), with 44 participants (46.8%) having held this role at least once. Additionally, a highly significant association was observed with co-authorship in the last 5 years (P < 0.0001), where 52 participants (55.3%) had contributed as co-authors at least once. However, there was no significant association between prior research experience and factors such as allocated research time (P = 0.280), level of practice (P = 0.147), years in practice (P = 0.826), or the number of patients seen per week (P = 0.885).

Research barriers and research participation goals

Multivariate analysis that considered all barriers was conducted, and the most selected barrier was insufficient research time (71; 67.7%), followed by the lack of research assistants (57; 54.3%) and inadequate research training (48; 45.7%). When the participants were asked to choose one single barrier as the most limiting, insufficient research time (32; 30.5%) followed by lack of research assistants (17; 16.2%) created the biggest barriers (Figure 1A).

Figure 1 Distribution of barriers and the most limiting factor for research participation and research participation goals among all survey respondents. A: Distribution of barriers and the single most limiting factor for research participation. It illustrates the frequency and types of challenges orthopedic surgeons face in conducting research; B: Distribution of research participation goals and the most important goals. It highlights the key motivations for engaging in research, as reported by the participants. CV: Curriculum vitae.

When the respondents were asked about their goals for research participation, improving their personal curriculum vitae (CV) was the most chosen option (68; 64.8%). Enhancement of research skills and promotion/reward came in second, as reported by 55 (52.4%) each. When asked what single goal was the most important to them, improvement of personal CV for promotion/reward was the most important (35 (33.3%) and 25 (23.8%), respectively) (Figure 1B).

When barriers and goals to research participation were identified based on the level of practice, the most limiting barrier or single important goal based on the level of practice residents, non-academic consultants, registrars, and fellows chose insufficient research time as the single most limiting barrier to research participation 14 (43.8%), 7 (21.9%), 5 (15.6%), 3 (9.4%) respectively. Furthermore, the most important goal for research participation for residents and fellows was the improvement of personal CV 19 (54.3%) and 9 (25.7%), respectively, where academic consultants chose personal interest in research activities 13 (48.1%), nonacademic consultants chose for promotion/reward 8 (32%) (Table 3).

Table 3 Single most limiting barrier or goal based on the level of practice, n (%).

Level of practice	Single most limiting barrier to research participation		Single most important goal for research participation
Resident	Insufficient research time	14 (43.8)	Improvement of personal CV	19 (54.3)
Fellow	Insufficient research time	3 (9.4)	Improvement of personal CV	9 (25.7)
Specialist	Insufficient research time	5 (15.6)	Enhancement of research skills	4 (28.6)
Consultant (academic)	Lack of research assistants	11 (64.7)	Personal interest in research activities	13 (48.1)
Consultant (non-academic)	Insufficient research time	7 (21.9)	For promotion/reward	8 (32)

CV: Curriculum vitae.

Finally, when barriers and goals to research participation were identified based on the respondents’ subspecialties, the most significant barrier to research was the lack of research assistants, particularly among arthroplasty surgeons (23.5%) and spine, oncology, upper extremity, and deformity surgeons (17.6% each). Regarding goals, general orthopedics, spine, and upper extremity surgeons prioritized personal research interest (14.8%), while pediatric orthopedics, sports medicine, orthopedic trauma, and deformity surgeons most valued promotion/reward as their primary goal (Table 4).

Table 4 Single most limiting barrier or goal based on subspecialties, n (%).

Subspecialty	Single most limiting barrier to research participation		Single most important goal for research participation
General orthopedics	Insufficient research time	5 (15.6)	Personal interest in research activities	4 (14.8)
Pediatric orthopedics	Lack of funding	4 (36.4)	For promotion/reward	9 (36)
Spine	Lack of research assistants	3 (17.6)	Personal interest in research activities	4 (14.8)
Foot and ankle	Insufficient research time	3 (9.4)	Improvement of personal curriculum vitae	3 (8.6)
Orthopedic oncology	Lack of research assistants	3 (17.6)	Personal interest in research activities	3 (11.1)
Orthopedic trauma	Lack of research collaboration	2 (33.3)	For promotion/reward	5 (20)
Sports medicine	Lack of funding	3 (27.3)	For promotion/reward	6 (24)
Upper extremity	Lack of research assistants	3 (17.6)	Personal interest in research activities	4 (14.8)
Arthroplasty	Lack of research assistants	4 (23.5)	Enhancement of research skills	5 (35.7)
Deformity	Lack of research assistants	3 (17.6)	For promotion/reward	3 (12)

DISCUSSION

Research plays a vital role in patient care and is highly valued because it provides various approaches that aid in informed decision-making. The main goal of this study was to identify the barriers that limit research productivity and the goals behind influencing research work among orthopedic surgeons. It also identified the major obstacles and challenges, allowing us to improve the research process from all aspects.

Most participants were interested and involved in research activities, but they faced multiple barriers. The participants were asked about all ten barriers, and the most frequently selected barrier was insufficient research time (71; 67.7%), followed by the lack of research assistants (57; 54.3%). These two barriers were each identified as the single most limiting barrier. Lack of funding, lack of statisticians, insufficient research training, lack of research collaboration, journal requirements for publication, lack of information technology and technical support, lack of rewards and incentives, and lack of personal research interest are all barriers that limit and challenge the development of research productivity. These findings echo prior regional studies that highlighted a persistent gap between research interest and productivity among orthopedic surgeons, due in large part to institutional and logistical limitations[8,10,15].

Contrary to our results, a multi-country study from Africa identified limited mentorship and inadequate funding as the most significant barriers to clinician-led research rather than insufficient time[8]. This contrast underscores how contextual and institutional factors, such as mentorship structures, funding availability, and administrative complexity, shape perceived barriers across different settings.

In this study, we identified multiple research participation goals, and the results showed that improving personal CV (68; 64.8%) was the most influential and the single most important goal. Enhancement of research skills and promotion/reward came in second with 55 (52.4%) each. Financial incentives, intrinsic interest in research, and the potential to improve patient outcomes were also essential motivators[6,11]. Conversely, time constraints were identified as the most common obstacle to research participation in several international studies[6,14].

Despite the various barriers reported by participants in our study, orthopedic surgeons in Saudi Arabia are showing an increasing interest in research, as evidenced by the growing number of publications. Our study found that 94 (89.5%) respondents had participated in at least one research project during their careers. The most commonly published study designs were case reports (76; 72.4%), retrospective studies (67; 63.8%), and cross-sectional studies (47; 44.8%).

Bibliometric evidence shows that Saudi Arabia’s orthopedic research output remains largely clustered in certain institutions and published in lower-impact regional journals[11]. Moreover, there is a persistent underrepresentation of Arab authors in Q1 orthopedic journals, highlighting a systemic issue in both access and international research integration[13]. These challenges align with other reports identifying insufficient research education, administrative complexity, and career-stage disincentives as root causes[3,4,10]. As another study emphasized in his commentary on local orthopedic research, efforts to strengthen publication ecosystems must be paired with real structural change[15]. Furthermore, recent classification frameworks for musculoskeletal research can help effectively target institutional interventions[14]. In addition, the research environment was described as lacking in infrastructural support, with insufficient access to trained research assistants and statistical expertise. Commentary on the national orthopedic research landscape has further emphasized that the current ecosystem lacks the flexibility, incentives, and academic structures necessary to support consistent scholarly engagement across all subspecialties[8,11,15]. These findings reinforce the urgent need for targeted reforms, particularly those that support underrepresented subspecialties and foster a more balanced and inclusive research environment.

Our study found a significant association between having conducted any previous research and being the primary investigator in the last 5 years, with 44 (46.8%) participants having held this role at least once. Additionally, 52 (55.3%) participants were co-authors at least once in the last 5 years, indicating a highly significant relationship. However, we did not identify a significant association between prior research and allocated research time, level of practice, years in practice, and number of patients seen weekly.

One of the most significant barrier to research was the lack of research assistants, particularly among arthroplasty surgeons (23.5%) and those in spine, oncology, upper extremity, and deformity subspecialties (17.6% each). In terms of research goals, general orthopedic surgeons, spine surgeons, and upper extremity surgeons prioritized personal research interest (14.8%), whereas pediatric orthopedic surgeons, sports medicine surgeons, orthopedic trauma surgeons, and deformity surgeons most valued promotion and reward as their primary goal. The most limiting barrier for academic consultants was the need for more research assistants. In contrast, more research time was needed among the non-academic consultants, registrars, fellows, and residents. The most important goal for academic consultants’ research participation was personal interest in research activities. The primary goal of non-academic consultants was promotion and reward, whereas residents and fellows focused on enhancing their personal CVs. On the other hand, the lack of research assistants was the main barrier among almost all orthopedic subspecialties. In contrast, personal interest, promotion, and reward were the most influential goals behind research participation across most orthopedic subspecialties.

Our findings have implications for national academic policy. Institutions should prioritize structured mentorship programs, provide protected research time, and recognize research output in performance evaluations, aligning with Saudi Vision 2030’s goals of promoting research excellence and innovation.

Given the challenges faced by orthopedic surgeons in Saudi Arabia in terms of research productivity, it is crucial for institutions to prioritize dedicated research time and provide robust support systems. Strengthening research training and mentorship, alongside increasing financial and institutional backing, can significantly improve research engagement. Simplifying administrative processes and fostering collaborative efforts will also play a vital role in encouraging participation. Moreover, recognizing and rewarding research achievements will help nurture a research-driven culture, ultimately enhancing evidence-based practices within the field. Furthermore, countries risk losing their most talented researchers due to inadequate research infrastructure and support, leading to brain drain, where skilled professionals seek better opportunities abroad[14]. Addressing these challenges is vital to retain local talent and advance the overall research landscape.

Because this was a cross-sectional study, causal relationships cannot be inferred. Future longitudinal research should explore how institutional reforms influence sustained research engagement and productivity over time.

CONCLUSION

Orthopedic surgeons in Saudi Arabia face multifaceted challenges that limit research productivity, including insufficient time, training, and support staff. Addressing these barriers through institutional reforms, such as protected research time, mentorship, and funding, could substantially enhance engagement. The findings offer practical insights for academic leaders and policymakers seeking to strengthen the national orthopedic research ecosystem. Future longitudinal studies should explore the long-term impact of such institutional initiatives.