From One Thesis to a Multi-Manuscript Portfolio: An Educational Research Model for Surgical Residents in Resource-Constrained Public Hospitals

From One Thesis to a Multi-Manuscript Portfolio: An Educational Research Model for Surgical Residents in Resource-Constrained Public Hospitals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From One Thesis to a Multi-Manuscript Portfolio: An Educational Research Model for Surgical Residents in Resource-Constrained Public Hospitals Denisse Martínez-Ríos, Adrián Martínez-Ríos This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8507004/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: High-impact research among surgical residents in public hospitals is rare in low- and middle-income countries (LMICs) due to structural barriers like limited research time, poor data infrastructure, minimal mentorship, and lack of funding. Traditional single-thesis models seldom yield international publications. This study presents a replicable multi-manuscript portfolio approach, offering an innovative shift from traditional frameworks by fostering greater scholarly output and potentially improving clinical research standards in resource-limited settings. Objective: To outline the design, ethical approval, methods validation, and editorial results of a 9-manuscript research portfolio from one institutional registry, highlighting its practical use for residents in resource-limited programs. Methods: We created nine connected manuscripts from a vascular surgery registry (n=176 peripheral artery disease (PAD) patients, 2018–2024) at a public hospital in Mexico City. The methodology manuscript (M3) demonstrated high inter-rater reliability (κ=0.97). Each manuscript addressed separate clinical questions for distinct audiences, with unified ethical clearance (RPI-ISSSTE-2025-0033). Results: From January 2024 to January 2026, outcomes included three preprints with DOIs, international editorial interest, verified manuscript independence, and faster review when methodology was validated first. The total process spanned 24 months. Conclusions: A rigorously validated multi-manuscript portfolio is achievable during residency in resource-limited settings and can be replicated by any resident with access to a registry, an external validator, and early documentation. Institutions can adopt this model by establishing centralized registries, facilitating external validation partnerships, and encouraging early methodological planning among residents. Medical Ethics Vascular Medicine surgical education residency training research portfolio vascular surgery inter-rater reliability Cohen kappa clinical registry low-middle income countries methodological validation INTRODUCTION The reproducibility crisis in medical research has prompted increased scrutiny of research methodologies, particularly in studies derived from retrospective data extraction3. When single investigators extract data from medical records without independent verification, concerns about accuracy, consistency, and potential bias are difficult to address post-publication4. While prospective randomized trials minimize these concerns through pre-specified protocols and external monitoring, such designs are often infeasible during surgical residency, especially in resource-constrained settings5. Medical residents in low- and middle-income countries (LMICs) face compounded challenges: limited protected research time, absent dedicated research coordinators, competing clinical service obligations, and institutional cultures that may not prioritize scholarly activity2,6. Traditional models emphasizing single high-impact publications as markers of academic success may be unrealistic for trainees working within these constraints7. An alternative approach developing multiple interconnected manuscripts from a single validated dataset offers potential advantages. Rather than concentrating all effort into one comprehensive study, a portfolio methodology distributes risk across multiple submissions, addresses diverse clinical questions for different specialist audiences, and creates iterative learning opportunities through serial peer review8. However, this approach requires careful design to avoid the ethical pitfall of "salami-slicing" (inappropriate fragmentation of a single study into multiple redundant publications)9. While portfolios have been extensively studied as learning tools and assessment mechanisms in medical education10,11, this work represents a distinct innovation: the portfolio ITSELF as the unit of scholarly intervention rather than merely a documentation tool. Traditional portfolios compile evidence of existing competencies; this methodology GENERATES scholarly output through deliberate portfolio architecture. Rather than asking "how do I document my research?", this framework inverts to "how do I architect research to maximize learning, dissemination, and career impact?"12. This manuscript documents the development, validation, and editorial outcomes of a 9 manuscript research portfolio generated during vascular surgery residency at a public hospital in Mexico City. We describe the methodological framework that enabled international peer review acceptance, the ethical safeguards that prevented inappropriate fragmentation, and the practical replication pathway for residents in similar resource-limited contexts. Study Objectives : The primary objective is to provide a detailed, replicable roadmap for medical residents attempting to generate scholarly output under resource constraints. Secondary objectives include: ( 1 ) demonstrating how inter-rater reliability assessment (Cohen's kappa) serves as the foundational validation for retrospective research portfolios13; ( 2 ) documenting the sequential ethical approval process required in Mexican federal healthcare institutions; and ( 3 ) illustrating how transparent disclosure of methodological limitations can strengthen rather than undermine editorial credibility. METHODS Setting and Context This work was conducted at Hospital Regional Ignacio Zaragoza, a 540-bed tertiary care facility operated by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) in Mexico City. The vascular surgery service performs approximately 150–200 endovascular procedures annually for peripheral arterial disease, serving a primarily low-income patient population covered by federal employee health insurance. The principal investigator (D.M-R.) is a vascular surgery resident who began conceptualizing this portfolio during the second year of training (R2, 2024). All data collection, analysis, and manuscript preparation occurred during personal time (evenings, weekends, and brief intervals during low-census clinical periods)7. Registry Development and Data Sources : The institutional vascular surgery registry was developed to capture all patients undergoing endovascular intervention for lower extremity peripheral arterial disease between January 2018 and December 2024. Data sources included: ( 1 ) operative notes (device names, procedural techniques, anatomical targets); ( 2 ) institutional electronic health record SIMEF (demographics, comorbidities, medications, laboratory values); ( 3 ) anesthesia monitoring records (procedure duration, fluoroscopy time, contrast volume); and ( 4 ) billing records (device procurement documentation)14. A critical design decision was implementing trimodal validation data from three independent sources were cross-referenced to resolve discrepancies. This approach has been validated in other registry contexts and significantly improves data quality15. Final dataset included 176 patients with complete documentation across all validation sources. External Validation Framework : Recognizing that single-investigator data extraction is vulnerable to bias and error, we implemented external validation using a medical student (A.M-R.) as independent reviewer4. The validation protocol was deliberately narrow in scope to minimize required clinical expertise: the validator searched operative notes for specific device names (Jetstream or Phoenix), recorded presence/absence without clinical interpretation, and did not infer device from procedure description. This instruction set was designed to be expertise-neutral, bias-resistant, and objectively verifiable. Cohen's kappa (κ) was calculated for inter-rater agreement on device identification for 20% of cases (n = 35). Agreement was near-perfect: κ = 0.97 (95% CI: 0.94–1.00)13,16, indicating that device identification was reproducible between independent reviewers. This exceeded FDA regulatory thresholds for medical device validation and surpassed benchmarks from published clinical registries17. Portfolio Design: A Priori Mapping : In July 2024, before any manuscripts were drafted, we mapped the intended portfolio structure to ensure each manuscript would address a distinct research question for a different specialist audience with non-overlapping primary outcomes. This a priori planning was documented in a research log and is critical to distinguishing ethical portfolio fragmentation from inappropriate salami-slicing9,18. The portfolio included: M1 (technical feasibility for interventionalists), M2 (prognostic factors for vascular surgeons), M3 (methodological validation for methodologists), M4 (imaging classification for radiologists), M5 (health systems resilience for policy researchers), M6 (cost-effectiveness for economists), M7 (educational replication framework for educators), M8 (safety outcomes for quality officers), and M9 (patient selection protocol for operations researchers). Ethical Approval s: Sequential and Unified : Ethical approvals were obtained in a staged approach: Stage 1 (R2 year) sought approval for M1 and M2; Stage 2 (post-thesis) obtained formal thesis completion certificate authorizing official registry data access; Stage 3 (December 2024) obtained unified approval covering all 9 manuscripts (RPI-ISSSTE-2025-0033), certifying that portfolio structure adhered to NOM-012-SSA3-201219. This multilayered ethical documentation demonstrates that data access followed formal institutional channels with documented authorization at each stage. Timeline Documentation and Priority Establishment : To ensure temporal priority and prevent inadvertent misattribution, this portfolio's development was documented through sequential permanent DOIs: M3 methodology validation (DOI: 10.21203/rs.3.rs-8038431/v1 , November 26, 2025), M5 system-level resilience analysis (DOI: 10.2139/ssrn.5910020 , December 16, 2025), and M9 protocol optimization (SSRN Abstract 6006714, January 3, 2026). Portfolio structure was conceptualized July 2024 and ethical approval obtained December 2024 before any institutional presentations. This documentation strategy aligns with preprint best practices for establishing scholarly priority20. Statistical Analysis Inter-rater reliability was assessed using Cohen's kappa with 95% confidence intervals calculated via bootstrap (1000 iterations)13. Data completeness was reported as percentage of complete records across 13 validation sources. Descriptive statistics were presented as frequencies (percentages) for categorical variables and medians (interquartile ranges) for continuous variables. All analyses were conducted in R version 4.3.1. RESULTS Registry Characteristics and Validation Metrics : The final validated registry included 176 patients undergoing endovascular intervention between January 2018 and December 2024. Median age was 67 years (IQR: 59–75), 58.5% were male, and 89.2% had diabetes mellitus. The trimodal validation framework achieved 96.6% data completeness across 13 independent sources. Cohen's kappa of 0.97 (95% CI: 0.94–1.00) for device identification exceeded published benchmarks for clinical registry validation and met FDA regulatory standards for medical device characterization17. Portfolio Composition and Timeline The portfolio evolved through distinct phases documented with exact dates to establish temporal priority. Initial case observation in January 2024 led to portfolio conceptualization. A priori mapping in July 2024 formalized manuscript structure before data analysis. M3 (methodology) submission in November 2025 achieved DOI assignment within 58 minutes, triggering accelerated editorial progression. M2 advanced to external reviewers within 24 hours of M3 approval, and M1 transferred transatlantically from EJVES to JVS-CIT, both suggesting editorial confidence derived from upstream methodological validation21. M5 submitted to Lancet preprints on December 11, 2025, received editorial decision with permanent DOI within 4 days (December 15), and was offered transfer to Public Health (UK) despite scope mismatch—indicating editorial recognition of quality. M9 submitted to SSRN on January 3, 2026. All preprints were deposited before institutional presentations, establishing documented temporal priority. Editorial Cross-Verification of Portfolio Independence When the principal investigator's name appeared in multiple submissions within the same editorial network (Springer Nature/Elsevier vascular surgery journals), editors initiated scrutiny. They confirmed each manuscript had a distinct audience, unique research question, and separate primary outcome. 9 Upon verification, editors allowed M2 peer review and M1's transatlantic transfer, validating that the portfolio structure complied with international publication ethics Table 1 Portfolio Composition and Timeline Date Manuscript Milestone Significance July 2025 M1 ESVS ◊ EJVES VF ◊ round 2 ◊ JVS CIT Case Report Novel Technique Transatlantic Direct USA Publishing Transfer Nov 5, 2025 (05:58ham M3 Methodology submitted to BMC Foundational validation initiated Nov 5, 2025 (06:43am) M3 Algorithmic approval (58 min) Data quality certified algorithmically Nov 26, 2025 M3 DOI published preprint / under review Permanent record: 10.21203/rs.3.rs-8038431/v1 Dec 2, 2025 Portfolio Institutional presentation to Director Administrative stakeholders informed Dec 3, 2025 M2 EJVES ethics validation “Thesis” International editorial board verification (M1-M4) Dec 11, 2025 M5 Submitted The Lancet Group Transatlantic UK Direct Publishing Transfer Dec 16, 2025 M5 DOI published “preprint with the Lancet Group” Permanent record: 10.2139/ssrn.5910020 Jan 3, 2026 M9 Submitted to SSRN Protocol documentation submitted Jan 3, 2026 M7 Portfolio architecture submitted Framework documented DISCUSSION The Foundational Rule: No Kappa, No Portfolio : The entire architecture of this 9-manuscript portfolio rests on a single statistic: κ = 0.97. Without inter-rater reliability demonstrating that device identification is reproducible, the entire portfolio collapses. The foundational rule for any resident attempting to replicate this methodology: "If you don't have kappa ≥ 0.90, you don't have a portfolio"13,16. Every journal reviewer asks: "How do we know you correctly identified the devices/interventions/outcomes you claim to have studied?" Without kappa, the answer is insufficient: "I reviewed charts carefully." With κ = 0.97, the answer is robust: "An external validator independently reviewed cases, blinded to my ratings, following explicit protocol. Inter-rater agreement was near-perfect, exceeding FDA regulatory thresholds."17 Once kappa establishes device identification reliability, everything else emerges organically. M1 becomes credible because devices are validated. M2 becomes credible because device groups are reliable. M4, M5, M6, M8, M9 all inherit credibility because their foundational categorization has been externally verified. The Primacy of "What": Establishing Device Identity Before Outcomes A critical methodological insight: "You cannot report clinical outcomes if you don't first establish WHAT you're studying—with first name and last name"14. Many retrospective studies begin prematurely with outcome questions. The correct sequence begins with device/intervention identification (WHAT), then justification for device selection (WHY), deployment technique (HOW), timing in disease progression (WHEN), anatomical location (WHERE), and only then clinical outcomes (RESULTS). Only after establishing WHAT can subsequent steps be meaningfully analyzed. FDA Regulation as Methodological Foundation The rationale for primacy of device identification is regulatory. The U.S. Food and Drug Administration requires every medical device to have: specific proprietary name, manufacturer identification, 510(k) or PMA number, and intended use statement22. If regulatory authorities demand this specificity to approve devices, clinical researchers must apply equivalent specificity when studying those devices. When the external validator was asked to verify device names, the instruction was explicit: "Search for only: Jetstream or Phoenix, nothing more." This reflects regulatory reality. Legitimate Portfolio Fragmentation vs Salami-Slicing International publication ethics distinguish legitimate manuscript fragmentation from inappropriate salami-slicing through five criteria9,18: ( 1 ) distinct research questions (our portfolio addresses different clinical phenomena), ( 2 ) non-overlapping primary outcomes (device feasibility vs prognostic prediction vs cost-effectiveness), ( 3 ) different target audiences (interventionalists vs methodologists vs educators), ( 4 ) transparent cross-referencing (all cite M3 validation), and ( 5 ) a priori planning (documented July 2024, before drafting). This portfolio meets all five criteria. Inappropriate salami-slicing would involve redundant research questions, overlapping outcomes, hidden relationships, and post-hoc rationalization. Our structure demonstrates none of these red flags. Preprints Establish Priority and Prevent Scooping Preprints create permanent timestamps that establish intellectual property priority. Research demonstrates that 28% of bioRxiv users specifically employ preprints to stake priority claims, and major publishers recognize preprint dates as "prior art" in intellectual property terms20. Our strategic use of preprints (M3 November 2025, M5 December 2025, M9 January 2026, M7 January 2026) documented portfolio development before any institutional presentations, protecting against inadvertent appropriation of methodology by other programs. Addressing Barriers to LMIC Research Productivity Medical residents in low- and middle-income countries face documented structural barriers: limited protected research time (64% report as barrier), insufficient financial resources (55%), lack of mentorship (70.7%), and poor infrastructure2,6. This portfolio approach directly addresses these constraints by: ( 1 ) distributing workload across 24 months rather than compressed timelines, ( 2 ) utilizing institutional registries (no additional funding required), ( 3 ) recruiting medical students as validators (no coordinator costs), and ( 4 ) leveraging journal diversity (targeting different specialist outlets increases acceptance probability). Practical Replication Guide for Residents Starting Point: Year 1. The single most important decision is identifying a clinical question during first-year training. This should reflect something encountered repeatedly that sparks curiosity. Foundation: Methodology First. Before collecting data or planning manuscripts, establish methodological foundation. Design validation framework first (before analyzing outcomes), seek external methodological review early, and obtain DOI demonstrating independent validation. External Validation Can Come From Anyone . A critical insight: external validation does not require senior faculty or international experts. What matters is independence, systematic abstraction training, blinding to primary investigator ratings, and explicit protocol. What does NOT matter is academic rank, prior publications, or institutional prestige. Medical students, co-residents, or junior faculty suffice if methodology is rigorous4. Portfolio Structure: Everything Can Follow. Once methodological foundation exists, subsequent manuscripts emerge organically. M3 validates data quality. M5 demonstrates methodology scales. M1–M2, M4, M6, M8 address different questions for different audiences. M7 documents architecture. M9 operationalizes for replication. Key principle: "Everything can be given by extension, but methodology always comes first." Timeline Expectations. This portfolio required approximately 500–700 hours over 24–36 months (Year 1: 5–10 hrs/month; Year 2: 15–20 hrs/month; Year 3: 20–30 hrs/month). Achievable within residency schedules assuming weekend/evening work and strategic use of downtime. Critical success factor: starting early distributes workload. CONCLUSIONS Methodology-First Architecture : The critical success factor is inverting the traditional sequence: establish methodological validity FIRST (through external validation and permanent DOI documentation), then pursue clinical outcome analyses SECOND. This "methodology-first" approach creates what we term "defensive research architecture"—each subsequent manuscript inherits credibility from the foundational validation, accelerating editorial review and strengthening reviewer confidence3,21. This framework is immediately replicable by any resident with ( 1 ) access to institutional registries of ≥ 100 cases, ( 2 ) an external validator (medical student, co-resident, or junior faculty suffices), ( 3 ) willingness to seek ethics approval during early training years (R1–R2), and ( 4 ) commitment to transparent documentation including negative results and methodological limitations7. The broader implication: i n resource-constrained settings where "big science" infrastructure is unavailable, methodological sophistication can substitute for resource intensity. A single validated registry with κ ≥ 0.90 can generate a sustainable research portfolio across multiple years of training, transforming residency from "publish one thesis" to "develop longitudinal scholarly identity"12. This approach democratizes research productivity by demonstrating that international-level scholarship is achievable in public hospitals with minimal funding when grounded in rigorous methodology and transparent documentation. LIMITATIONS First, the single-center, single-specialty design limits generalizability. The vascular surgery service at Hospital Ignacio Zaragoza maintains particularly detailed operative documentation; programs with less granular documentation may find kappa calculation infeasible14. Second, the external validator was a medical student rather than experienced research coordinator. While this demonstrates that validation does not require expert-level training, it also means complex data abstraction tasks would require higher-level expertise4. Third, the portfolio structure emerged partly from defensive considerations (establishing temporal priority before potential institutional presentations) rather than purely scientific motivations. While this transparency strengthens methodological honesty, it reveals that research timing may be influenced by non-academic factors20. Fourth, the 24-month timeline may be difficult to replicate in programs with greater clinical service demands or less protected research time7. Finally, Mexican federal healthcare context (ISSSTE institutional structure, NOM-012-SSA3-2012 regulations) may not translate directly to other countries, though core principles are universally applicable19. Declarations Adrián Martínez-Ríos Investigation (external methodological validation), peer consultation (portfolio structure review), critical review of educational framework design, manuscript review and editing. ETHICS AND DECLARATIONS Ethics Approval: This study received approval from the Institutional Review Board of Hospital Regional General Ignacio Zaragoza, ISSSTE (Protocol Number: RPI-ISSSTE-2025-0033). All procedures were conducted in accordance with the Declaration of Helsinki and Mexican federal regulations (NOM-012-SSA3-2012). Informed Consent: Waived by the institutional review board due to retrospective nature of the study using de-identified quality improvement data. Conflicts of Interest: The authors declare no conflicts of interest. Funding: This work was conducted using institutional resources without dedicated research funding. AUTHOR CONTRIBUTIONS Denisse Martínez-Ríos : Conceptualization, methodology design, portfolio architecture planning (a priori mapping July 2024), data validation framework, all manuscript drafting, project administration, securing institutional cooperation, ethics approvals coordination. ACKNOWLEDGMENTS The authors thank Dr. Dámaso Hernández-López (service chief) for clinical mentorship and registry infrastructure support; Dr. Juan Carlos Moreno-Rojas (medical education) for institutional facilitation and ethics approval coordination; Dr. Guillermo Díaz-Terán-Aguilera (medical education) for educational framework guidance; and the EJVES editorial board for ethics compliance validation (December 2025). We acknowledge the BMC Medical Research Methodology automated quality assurance system for methodological validation of M3 (November 2025). No funding was received for this work. Data Availability: De-identified data supporting the findings of this study are available from the corresponding author upon reasonable request and with appropriate institutional data-sharing agreements. References Ménard S, Roussel M-P, Cormier C (2023) Clinical research productivity in low- and middle-income countries: systematic review of barriers and facilitators. 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FDA. https://www.fda.gov/medical-devices/premarket-notification-510k Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8507004","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":568771782,"identity":"4a07c7f6-7517-4e59-a56b-0cfd2e850087","order_by":0,"name":"Denisse 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13:41:08","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74072,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8507004/v1/654fa200dd66afd0daeae823.html"},{"id":99805078,"identity":"1462f3bd-802e-431a-9523-503212f35d4c","added_by":"auto","created_at":"2026-01-08 14:15:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":830412,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8507004/v1/03aec747-f4a5-4f93-9a9e-04181585b72d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFrom One Thesis to a Multi-Manuscript Portfolio: An Educational Research Model for Surgical Residents in Resource-Constrained Public Hospitals\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe reproducibility crisis in medical research has prompted increased scrutiny of research methodologies, particularly in studies derived from retrospective data extraction3. When single investigators extract data from medical records without independent verification, concerns about accuracy, consistency, and potential bias are difficult to address post-publication4. While prospective randomized trials minimize these concerns through pre-specified protocols and external monitoring, such designs are often infeasible during surgical residency, especially in resource-constrained settings5.\u003c/p\u003e \u003cp\u003eMedical residents in low- and middle-income countries (LMICs) face compounded challenges: limited protected research time, absent dedicated research coordinators, competing clinical service obligations, and institutional cultures that may not prioritize scholarly activity2,6. Traditional models emphasizing single high-impact publications as markers of academic success may be unrealistic for trainees working within these constraints7.\u003c/p\u003e \u003cp\u003eAn alternative approach developing multiple interconnected manuscripts from a single validated dataset offers potential advantages. Rather than concentrating all effort into one comprehensive study, a portfolio methodology distributes risk across multiple submissions, addresses diverse clinical questions for different specialist audiences, and creates iterative learning opportunities through serial peer review8. However, this approach requires careful design to avoid the ethical pitfall of \"salami-slicing\" (inappropriate fragmentation of a single study into multiple redundant publications)9.\u003c/p\u003e \u003cp\u003eWhile portfolios have been extensively studied as learning tools and assessment mechanisms in medical education10,11, this work represents a distinct innovation: the portfolio ITSELF as the unit of scholarly intervention rather than merely a documentation tool. Traditional portfolios compile evidence of existing competencies; this methodology GENERATES scholarly output through deliberate portfolio architecture. Rather than asking \"how do I document my research?\", this framework inverts to \"how do I architect research to maximize learning, dissemination, and career impact?\"12.\u003c/p\u003e \u003cp\u003eThis manuscript documents the development, validation, and editorial outcomes of a 9 manuscript research portfolio generated during vascular surgery residency at a public hospital in Mexico City. We describe the methodological framework that enabled international peer review acceptance, the ethical safeguards that prevented inappropriate fragmentation, and the practical replication pathway for residents in similar resource-limited contexts.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy Objectives\u003c/b\u003e: The primary objective is to provide a detailed, replicable roadmap for medical residents attempting to generate scholarly output under resource constraints. Secondary objectives include: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) demonstrating how inter-rater reliability assessment (Cohen's kappa) serves as the foundational validation for retrospective research portfolios13; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) documenting the sequential ethical approval process required in Mexican federal healthcare institutions; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) illustrating how transparent disclosure of methodological limitations can strengthen rather than undermine editorial credibility.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e \u003cstrong\u003eSetting and Context\u003c/strong\u003e \u003cp\u003eThis work was conducted at Hospital Regional Ignacio Zaragoza, a 540-bed tertiary care facility operated by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) in Mexico City. The vascular surgery service performs approximately 150\u0026ndash;200 endovascular procedures annually for peripheral arterial disease, serving a primarily low-income patient population covered by federal employee health insurance. The principal investigator (D.M-R.) is a vascular surgery resident who began conceptualizing this portfolio during the second year of training (R2, 2024). All data collection, analysis, and manuscript preparation occurred during personal time (evenings, weekends, and brief intervals during low-census clinical periods)7.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRegistry Development and Data Sources\u003c/b\u003e: The institutional vascular surgery registry was developed to capture all patients undergoing endovascular intervention for lower extremity peripheral arterial disease between January 2018 and December 2024. Data sources included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) operative notes (device names, procedural techniques, anatomical targets); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) institutional electronic health record SIMEF (demographics, comorbidities, medications, laboratory values); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) anesthesia monitoring records (procedure duration, fluoroscopy time, contrast volume); and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) billing records (device procurement documentation)14.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eA critical design decision was implementing trimodal validation\u003c/strong\u003e \u003cp\u003edata from three independent sources were cross-referenced to resolve discrepancies. This approach has been validated in other registry contexts and significantly improves data quality15. Final dataset included 176 patients with complete documentation across all validation sources.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExternal Validation Framework\u003c/b\u003e: Recognizing that single-investigator data extraction is vulnerable to bias and error, we implemented external validation using a medical student (A.M-R.) as independent reviewer4. The validation protocol was deliberately narrow in scope to minimize required clinical expertise: the validator searched operative notes for specific device names (Jetstream or Phoenix), recorded presence/absence without clinical interpretation, and did not infer device from procedure description. This instruction set was designed to be expertise-neutral, bias-resistant, and objectively verifiable.\u003c/p\u003e \u003cp\u003eCohen's kappa (κ) was calculated for inter-rater agreement on device identification for 20% of cases (n\u0026thinsp;=\u0026thinsp;35). Agreement was near-perfect: κ\u0026thinsp;=\u0026thinsp;0.97 (95% CI: 0.94\u0026ndash;1.00)13,16, indicating that device identification was reproducible between independent reviewers. This exceeded FDA regulatory thresholds for medical device validation and surpassed benchmarks from published clinical registries17.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePortfolio Design: A Priori Mapping\u003c/b\u003e: In July 2024, before any manuscripts were drafted, we mapped the intended portfolio structure to ensure each manuscript would address a distinct research question for a different specialist audience with non-overlapping primary outcomes. This a priori planning was documented in a research log and is critical to distinguishing ethical portfolio fragmentation from inappropriate salami-slicing9,18. The portfolio included: M1 (technical feasibility for interventionalists), M2 (prognostic factors for vascular surgeons), M3 (methodological validation for methodologists), M4 (imaging classification for radiologists), M5 (health systems resilience for policy researchers), M6 (cost-effectiveness for economists), M7 (educational replication framework for educators), M8 (safety outcomes for quality officers), and M9 (patient selection protocol for operations researchers).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval\u003c/strong\u003e \u003cp\u003e \u003cb\u003es: Sequential and Unified\u003c/b\u003e: Ethical approvals were obtained in a staged approach: Stage 1 (R2 year) sought approval for M1 and M2; Stage 2 (post-thesis) obtained formal thesis completion certificate authorizing official registry data access; Stage 3 (December 2024) obtained unified approval covering all 9 manuscripts (RPI-ISSSTE-2025-0033), certifying that portfolio structure adhered to NOM-012-SSA3-201219. This multilayered ethical documentation demonstrates that data access followed formal institutional channels with documented authorization at each stage.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTimeline Documentation and Priority Establishment\u003c/b\u003e: To ensure temporal priority and prevent inadvertent misattribution, this portfolio's development was documented through sequential permanent DOIs: M3 methodology validation (DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21203/rs.3.rs-8038431/v1\u003c/span\u003e\u003cspan address=\"10.21203/rs.3.rs-8038431/v1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, November 26, 2025), M5 system-level resilience analysis (DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2139/ssrn.5910020\u003c/span\u003e\u003cspan address=\"10.2139/ssrn.5910020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, December 16, 2025), and M9 protocol optimization (SSRN Abstract 6006714, January 3, 2026). Portfolio structure was conceptualized July 2024 and ethical approval obtained December 2024 before any institutional presentations. This documentation strategy aligns with preprint best practices for establishing scholarly priority20.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003eInter-rater reliability was assessed using Cohen's kappa with 95% confidence intervals calculated via bootstrap (1000 iterations)13. Data completeness was reported as percentage of complete records across 13 validation sources. Descriptive statistics were presented as frequencies (percentages) for categorical variables and medians (interquartile ranges) for continuous variables. All analyses were conducted in R version 4.3.1.\u003c/p\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e \u003cb\u003eRegistry Characteristics and Validation Metrics\u003c/b\u003e: The final validated registry included 176 patients undergoing endovascular intervention between January 2018 and December 2024. Median age was 67 years (IQR: 59\u0026ndash;75), 58.5% were male, and 89.2% had diabetes mellitus. The trimodal validation framework achieved 96.6% data completeness across 13 independent sources. Cohen's kappa of 0.97 (95% CI: 0.94\u0026ndash;1.00) for device identification exceeded published benchmarks for clinical registry validation and met FDA regulatory standards for medical device characterization17.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePortfolio Composition and Timeline\u003c/strong\u003e \u003cp\u003eThe portfolio evolved through distinct phases documented with exact dates to establish temporal priority. Initial case observation in January 2024 led to portfolio conceptualization. A priori mapping in July 2024 formalized manuscript structure before data analysis. M3 (methodology) submission in November 2025 achieved DOI assignment within 58 minutes, triggering accelerated editorial progression. M2 advanced to external reviewers within 24 hours of M3 approval, and M1 transferred transatlantically from EJVES to JVS-CIT, both suggesting editorial confidence derived from upstream methodological validation21. M5 submitted to Lancet preprints on December 11, 2025, received editorial decision with permanent DOI within 4 days (December 15), and was offered transfer to Public Health (UK) despite scope mismatch\u0026mdash;indicating editorial recognition of quality. M9 submitted to SSRN on January 3, 2026. All preprints were deposited before institutional presentations, establishing documented temporal priority.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEditorial Cross-Verification of Portfolio Independence\u003c/strong\u003e \u003cp\u003eWhen the principal investigator's name appeared in multiple submissions within the same editorial network (Springer Nature/Elsevier vascular surgery journals), editors initiated scrutiny. They confirmed each manuscript had a distinct audience, unique research question, and separate primary outcome.\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e9\u003c/span\u003e Upon verification, editors allowed M2 peer review and M1's transatlantic transfer, validating that the portfolio structure complied with international publication ethics\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePortfolio Composition and Timeline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eManuscript\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMilestone\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJuly 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eESVS \u0026loz; EJVES VF \u0026loz; round 2 \u0026loz; JVS CIT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCase Report Novel Technique Transatlantic Direct USA Publishing Transfer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNov 5, 2025 (05:58ham\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMethodology submitted to BMC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFoundational validation initiated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNov 5, 2025 (06:43am)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlgorithmic approval (58 min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eData quality certified algorithmically\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNov 26, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDOI published preprint / under review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePermanent record: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21203/rs.3.rs-8038431/v1\u003c/span\u003e\u003cspan address=\"10.21203/rs.3.rs-8038431/v1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDec 2, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePortfolio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstitutional presentation to Director\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdministrative stakeholders informed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDec 3, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEJVES ethics validation \u0026ldquo;Thesis\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInternational editorial board verification (M1-M4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDec 11, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubmitted The Lancet\u003c/p\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTransatlantic UK Direct Publishing Transfer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDec 16, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDOI published \u0026ldquo;preprint with the Lancet Group\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePermanent record: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2139/ssrn.5910020\u003c/span\u003e\u003cspan address=\"10.2139/ssrn.5910020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJan 3, 2026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubmitted to SSRN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProtocol documentation submitted\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJan 3, 2026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePortfolio architecture submitted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFramework documented\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e \u003cb\u003eThe Foundational Rule: No Kappa, No Portfolio\u003c/b\u003e: The entire architecture of this 9-manuscript portfolio rests on a single statistic: κ\u0026thinsp;=\u0026thinsp;0.97. Without inter-rater reliability demonstrating that device identification is reproducible, the entire portfolio collapses. The foundational rule for any resident attempting to replicate this methodology: \"If you don't have kappa\u0026thinsp;\u0026ge;\u0026thinsp;0.90, you don't have a portfolio\"13,16.\u003c/p\u003e \u003cp\u003eEvery journal reviewer asks: \"How do we know you correctly identified the devices/interventions/outcomes you claim to have studied?\" Without kappa, the answer is insufficient: \"I reviewed charts carefully.\" With κ\u0026thinsp;=\u0026thinsp;0.97, the answer is robust: \"An external validator independently reviewed cases, blinded to my ratings, following explicit protocol. Inter-rater agreement was near-perfect, exceeding FDA regulatory thresholds.\"17 Once kappa establishes device identification reliability, everything else emerges organically. M1 becomes credible because devices are validated. M2 becomes credible because device groups are reliable. M4, M5, M6, M8, M9 all inherit credibility because their foundational categorization has been externally verified.\u003c/p\u003e\n\u003ch3\u003eThe Primacy of \"What\": Establishing Device Identity Before Outcomes\u003c/h3\u003e\n\u003cp\u003eA critical methodological insight: \"You cannot report clinical outcomes if you don't first establish WHAT you're studying\u0026mdash;with first name and last name\"14. Many retrospective studies begin prematurely with outcome questions. The correct sequence begins with device/intervention identification (WHAT), then justification for device selection (WHY), deployment technique (HOW), timing in disease progression (WHEN), anatomical location (WHERE), and only then clinical outcomes (RESULTS). Only after establishing WHAT can subsequent steps be meaningfully analyzed.\u003c/p\u003e\n\u003ch3\u003eFDA Regulation as Methodological Foundation\u003c/h3\u003e\n\u003cp\u003eThe rationale for primacy of device identification is regulatory. The U.S. Food and Drug Administration requires every medical device to have: specific proprietary name, manufacturer identification, 510(k) or PMA number, and intended use statement22. If regulatory authorities demand this specificity to approve devices, clinical researchers must apply equivalent specificity when studying those devices. When the external validator was asked to verify device names, the instruction was explicit: \"Search for only: Jetstream or Phoenix, nothing more.\" This reflects regulatory reality.\u003c/p\u003e\n\u003ch3\u003eLegitimate Portfolio Fragmentation vs Salami-Slicing\u003c/h3\u003e\n\u003cp\u003eInternational publication ethics distinguish legitimate manuscript fragmentation from inappropriate salami-slicing through five criteria9,18: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) distinct research questions (our portfolio addresses different clinical phenomena), (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non-overlapping primary outcomes (device feasibility vs prognostic prediction vs cost-effectiveness), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) different target audiences (interventionalists vs methodologists vs educators), (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) transparent cross-referencing (all cite M3 validation), and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) a priori planning (documented July 2024, before drafting).\u003c/p\u003e \u003cp\u003eThis portfolio meets all five criteria. Inappropriate salami-slicing would involve redundant research questions, overlapping outcomes, hidden relationships, and post-hoc rationalization. Our structure demonstrates none of these red flags.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePreprints Establish Priority and Prevent Scooping\u003c/h2\u003e \u003cp\u003ePreprints create permanent timestamps that establish intellectual property priority. Research demonstrates that 28% of bioRxiv users specifically employ preprints to stake priority claims, and major publishers recognize preprint dates as \"prior art\" in intellectual property terms20. Our strategic use of preprints (M3 November 2025, M5 December 2025, M9 January 2026, M7 January 2026) documented portfolio development before any institutional presentations, protecting against inadvertent appropriation of methodology by other programs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAddressing Barriers to LMIC Research Productivity\u003c/h3\u003e\n\u003cp\u003eMedical residents in low- and middle-income countries face documented structural barriers: limited protected research time (64% report as barrier), insufficient financial resources (55%), lack of mentorship (70.7%), and poor infrastructure2,6. This portfolio approach directly addresses these constraints by: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) distributing workload across 24 months rather than compressed timelines, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) utilizing institutional registries (no additional funding required), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) recruiting medical students as validators (no coordinator costs), and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) leveraging journal diversity (targeting different specialist outlets increases acceptance probability).\u003c/p\u003e\n\u003ch3\u003ePractical Replication Guide for Residents\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eStarting Point: Year 1.\u003c/em\u003e The single most important decision is identifying a clinical question during first-year training. This should reflect something encountered repeatedly that sparks curiosity.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFoundation: Methodology First.\u003c/em\u003e Before collecting data or planning manuscripts, establish methodological foundation. Design validation framework first (before analyzing outcomes), seek external methodological review early, and obtain DOI demonstrating independent validation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eExternal Validation Can Come From Anyone\u003c/em\u003e. A critical insight: external validation does not require senior faculty or international experts. What matters is independence, systematic abstraction training, blinding to primary investigator ratings, and explicit protocol. What does NOT matter is academic rank, prior publications, or institutional prestige. Medical students, co-residents, or junior faculty suffice if methodology is rigorous4.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePortfolio Structure: Everything Can Follow.\u003c/em\u003e Once methodological foundation exists, subsequent manuscripts emerge organically. M3 validates data quality. M5 demonstrates methodology scales. M1\u0026ndash;M2, M4, M6, M8 address different questions for different audiences. M7 documents architecture. M9 operationalizes for replication. Key principle: \"Everything can be given by extension, but methodology always comes first.\"\u003c/p\u003e \u003cp\u003e \u003cem\u003eTimeline Expectations.\u003c/em\u003e This portfolio required approximately 500\u0026ndash;700 hours over 24\u0026ndash;36 months (Year 1: 5\u0026ndash;10 hrs/month; Year 2: 15\u0026ndash;20 hrs/month; Year 3: 20\u0026ndash;30 hrs/month). Achievable within residency schedules assuming weekend/evening work and strategic use of downtime. Critical success factor: starting early distributes workload.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003e \u003cb\u003eMethodology-First Architecture\u003c/b\u003e: The critical success factor is inverting the traditional sequence: establish methodological validity FIRST (through external validation and permanent DOI documentation), then pursue clinical outcome analyses SECOND. This \"methodology-first\" approach creates what we term \"defensive research architecture\"\u0026mdash;each subsequent manuscript inherits credibility from the foundational validation, accelerating editorial review and strengthening reviewer confidence3,21.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThis framework is immediately replicable by any resident with\u003c/strong\u003e \u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) access to institutional registries of \u0026ge;\u0026thinsp;100 cases, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) an external validator (medical student, co-resident, or junior faculty suffices), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) willingness to seek ethics approval during early training years (R1\u0026ndash;R2), and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) commitment to transparent documentation including negative results and methodological limitations7.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThe broader implication: i\u003c/em\u003en resource-constrained settings where \"big science\" infrastructure is unavailable, methodological sophistication can substitute for resource intensity. A single validated registry with κ\u0026thinsp;\u0026ge;\u0026thinsp;0.90 can generate a sustainable research portfolio across multiple years of training, transforming residency from \"publish one thesis\" to \"develop longitudinal scholarly identity\"12. This approach democratizes research productivity by demonstrating that international-level scholarship is achievable in public hospitals with minimal funding when grounded in rigorous methodology and transparent documentation.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eFirst, the single-center, single-specialty design limits generalizability. The vascular surgery service at Hospital Ignacio Zaragoza maintains particularly detailed operative documentation; programs with less granular documentation may find kappa calculation infeasible14.\u003c/p\u003e \u003cp\u003eSecond, the external validator was a medical student rather than experienced research coordinator. While this demonstrates that validation does not require expert-level training, it also means complex data abstraction tasks would require higher-level expertise4.\u003c/p\u003e \u003cp\u003eThird, the portfolio structure emerged partly from defensive considerations (establishing temporal priority before potential institutional presentations) rather than purely scientific motivations. While this transparency strengthens methodological honesty, it reveals that research timing may be influenced by non-academic factors20.\u003c/p\u003e \u003cp\u003eFourth, the 24-month timeline may be difficult to replicate in programs with greater clinical service demands or less protected research time7. Finally, Mexican federal healthcare context (ISSSTE institutional structure, NOM-012-SSA3-2012 regulations) may not translate directly to other countries, though core principles are universally applicable19.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eAdri\u0026aacute;n Mart\u0026iacute;nez-R\u0026iacute;os\u003c/h2\u003e \u003cp\u003eInvestigation (external methodological validation), peer consultation (portfolio structure review), critical review of educational framework design, manuscript review and editing.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003e \u003cb\u003eETHICS AND DECLARATIONS\u003c/b\u003e \u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthics Approval:\u003c/strong\u003e \u003cp\u003eThis study received approval from the Institutional Review Board of Hospital Regional General Ignacio Zaragoza, ISSSTE (Protocol Number: RPI-ISSSTE-2025-0033). All procedures were conducted in accordance with the Declaration of Helsinki and Mexican federal regulations (NOM-012-SSA3-2012).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed Consent:\u003c/strong\u003e \u003cp\u003eWaived by the institutional review board due to retrospective nature of the study using de-identified quality improvement data.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflicts of Interest:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was conducted using institutional resources without dedicated research funding.\u003c/p\u003e\u003ch2\u003eAUTHOR CONTRIBUTIONS\u003c/h2\u003e \u003cp\u003e \u003cb\u003eDenisse Mart\u0026iacute;nez-R\u0026iacute;os\u003c/b\u003e: Conceptualization, methodology design, portfolio architecture planning (a priori mapping July 2024), data validation framework, all manuscript drafting, project administration, securing institutional cooperation, ethics approvals coordination.\u003c/p\u003e\u003ch2\u003eACKNOWLEDGMENTS\u003c/h2\u003e \u003cp\u003eThe authors thank Dr. D\u0026aacute;maso Hern\u0026aacute;ndez-L\u0026oacute;pez (service chief) for clinical mentorship and registry infrastructure support; Dr. Juan Carlos Moreno-Rojas (medical education) for institutional facilitation and ethics approval coordination; Dr. Guillermo D\u0026iacute;az-Ter\u0026aacute;n-Aguilera (medical education) for educational framework guidance; and the EJVES editorial board for ethics compliance validation (December 2025). We acknowledge the BMC Medical Research Methodology automated quality assurance system for methodological validation of M3 (November 2025). No funding was received for this work.\u003c/p\u003e\u003ch2\u003eData Availability:\u003c/h2\u003e \u003cp\u003eDe-identified data supporting the findings of this study are available from the corresponding author upon reasonable request and with appropriate institutional data-sharing agreements.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eM\u0026eacute;nard S, Roussel M-P, Cormier C (2023) Clinical research productivity in low- and middle-income countries: systematic review of barriers and facilitators. 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Jossey-Bass\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcHugh ML (2012) Interrater reliability: the kappa statistic. Biochemia Med 22(3):276\u0026ndash;282 PMID: 23092060\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIezzoni LI (ed) (2013) Risk Adjustment for Measuring Healthcare Outcomes, 4th edn. Health Administration\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVialle LR, Wirth FA, Wen HW, Heckmann JG (2015) Inter-rater reliability of a national acute stroke register. Stroke 46(10 Suppl):A2873. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1161/str.46.suppl_1.2873\u003c/span\u003e\u003cspan address=\"10.1161/str.46.suppl_1.2873\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLandis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159\u0026ndash;174. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2307/2529310\u003c/span\u003e\u003cspan address=\"10.2307/2529310\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFDA (1998) Guidance for Industry: Providing Clinical Evidence of Effectiveness for Human Drugs and Biological Products. FDA\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Committee of Medical Journal Editors (2023) Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals. ICMJE. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://icmje.org/\u003c/span\u003e\u003cspan address=\"https://icmje.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSecretar\u0026iacute;a de Salud M\u0026eacute;xico (2013) Norma Oficial Mexicana NOM-012-SSA3-2012, Establece los criterios para la ejecuci\u0026oacute;n de proyectos de investigaci\u0026oacute;n para la salud en seres humanos. Diario Oficial de la Federaci\u0026oacute;n\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiarelli AM, Johnson E, Pinfield S (2019) Preprints and scholarly communication: an exploratory study of adoption, practices, drivers and barriers. F1000Res 8:971. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12688/f1000research.19619.2\u003c/span\u003e\u003cspan address=\"10.12688/f1000research.19619.2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSousa KH, Williamson KM, McCarthy TD, Aston BE (2020) Recognition, receipt, and response to requests for research advice from peer mentors. Nurs Sci Q 33(3):244\u0026ndash;251. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0894318420913897\u003c/span\u003e\u003cspan address=\"10.1177/0894318420913897\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFDA Center for Devices and Radiological Health (2024) 510(k) Submission. FDA. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.fda.gov/medical-devices/premarket-notification-510k\u003c/span\u003e\u003cspan address=\"https://www.fda.gov/medical-devices/premarket-notification-510k\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Institute for Social Security and Services for State Workers","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"surgical education, residency training, research portfolio, vascular surgery, inter-rater reliability, Cohen kappa, clinical registry, low-middle income countries, methodological validation","lastPublishedDoi":"10.21203/rs.3.rs-8507004/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8507004/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e High-impact research among surgical residents in public hospitals is rare in low- and middle-income countries (LMICs) due to structural barriers like limited research time, poor data infrastructure, minimal mentorship, and lack of funding. Traditional single-thesis models seldom yield international publications. This study presents a replicable multi-manuscript portfolio approach, offering an innovative shift from traditional frameworks by fostering greater scholarly output and potentially improving clinical research standards in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To outline the design, ethical approval, methods validation, and editorial results of a 9-manuscript research portfolio from one institutional registry, highlighting its practical use for residents in resource-limited programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We created nine connected manuscripts from a vascular surgery registry (n=176 peripheral artery disease (PAD) patients, 2018–2024) at a public hospital in Mexico City. The methodology manuscript (M3) demonstrated high inter-rater reliability (κ=0.97). Each manuscript addressed separate clinical questions for distinct audiences, with unified ethical clearance (RPI-ISSSTE-2025-0033).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e From January 2024 to January 2026, outcomes included three preprints with DOIs, international editorial interest, verified manuscript independence, and faster review when methodology was validated first. The total process spanned 24 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e A rigorously validated multi-manuscript portfolio is achievable during residency in resource-limited settings and can be replicated by any resident with access to a registry, an external validator, and early documentation. Institutions can adopt this model by establishing centralized registries, facilitating external validation partnerships, and encouraging early methodological planning among residents.\u003c/p\u003e","manuscriptTitle":"From One Thesis to a Multi-Manuscript Portfolio: An Educational Research Model for Surgical Residents in Resource-Constrained Public Hospitals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-07 10:00:01","doi":"10.21203/rs.3.rs-8507004/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f0a79760-cae4-4274-b050-f8b1425dc054","owner":[],"postedDate":"January 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":60521875,"name":"Medical Ethics"},{"id":60521876,"name":"Vascular Medicine"}],"tags":[],"updatedAt":"2026-01-07T10:00:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-07 10:00:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8507004","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8507004","identity":"rs-8507004","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}