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Research in Emergency Medicine training: one straw too many?

Author: Carrie Thomas / Editor: Charlotte Kennedy / Codes: CC20, HAP29 / Published: 28/08/2018

Emergency Medicine (EM) is demanding, especially at the moment where crowding and exit block challenge us daily to deliver care for even the patients right in front of us. EM is a speciality where we have the privilege to care for the undifferentiated patient, seeing the full spectrum of ages in their time of need. Even if that need is a low acuity presentation needing only an explanation or reassurance, the demand for service provision is high. Yet sadly our educational and developmental needs as EM trainees, who are the consultants and leaders for the future of our speciality, are frequently side-lined as a result of these demands.

ARCPs and Structured Training Reports

During one of my pre-ARCP meetings my Educational Supervisor and I were going through the Structured Training Report. When we came to the “research box” he quickly said:

“Don’t worry about that box, nobody ever has anything.”

This left me with mixed feelings: of relief that I wasn’t behind the curve and that there was one less “hoop to jump through”, but also an uneasiness as research was something I’d like to do and felt was important. It’s also mentioned on our curriculum (CC20 and HAP29) specifically.

So why don’t we become involved in research?

To be honest at that stage of my career, being LTFT for competitive sport, I didn’t have the time, energy or direction to pursue or develop any of my research ideas I was interested in. Rightly or wrongly, I think I self-allocated myself to the “sporty” end of my imaginary “sport-academic” spectrum, telling myself that I couldn’t compete in sport and expect to partake in research as well, on top of all the other demands (WPBAs, exams, audit, mandatory courses, teaching, guideline writing, QIP etc.) expected of EM trainees.

There are different reasons for us all that we may have not yet become involved in research, but now the College seem to be taking interest in the reasons why. RCEM are keen to know more about these barriers – please do take a moment to complete this questionnaire1if you haven’t already.

Exposure and involvement in research at work

Upon reflection though, I suppose I have trained in hospitals participating in clinical trials. As such, I have been exposed to the “clinical end” of remembering to think about eligibility and recruitment into specific trials. I’ve seen both the research nurses’ numbers and the number of clinical trials grow under the guidance of a dedicated Nurse Consultant. I’ve been exposed to teaching sessions where in the explanation of NOACs/DOACs the presenter quickly mentions the new trial planned for reversal agents. Our ED guidelines were based on best current evidence and reviewed routinely for any updates. We expected that new or updated guidelines would hit our inboxes and be updated on the intranet as the collective growth mind-set of the ED strove to deliver excellence in care for our patients.

During a quality improvement project (QIP), the suggestion from my supervisor to submit our work to the RCEM Annual Scientific Conference was one of the key turning points for me. What had seemed hard to achieve in terms of an abstract being accepted at a national conference was suddenly actually just like writing up an experiment done in the lab at school. Only this one was showing an improvement in time to analgesia in children, not counting fruit flies! What had once been a solitary piece of work in a notebook was now an interactive and collaborative group activity thanks to email and file sharing. This is research!

Time spent attending such conferences over the past few years has been a welcome opportunity. Not just to learn about what we do, but why we do it and how could it be better. For those wanting to be kept up-to-date without the time and expense of attending conferences, the knowledge translation strategies available using #FOAMed and high quality blogs published by fellow EM colleagues is well documented and gets a great deal of buy in from the majority of our specialty the St Emlyns website reports 1.25 million hits since 2012, with linear growth annually2.

So, I kept going back. At my second time RCEM Annual Scientific conference I was pleasantly surprised that my use of #FOAMed meant that I had already heard and read about all the “Top 10 Papers of 2017” as presented and explained by Professor Rick Body in one of the keynote sessions. #FOAMed had enabled me to keep up to date with the research.

In addition to the variety of research presented throughout the three days there was a research stream on the final afternoon with Ellen Weber, the EMJ Editor, who presented on “Getting Published”.

The overall summary of priorities for the editor and the reader is summarised in the table below:

To the Editor To the Reader
What’s most important? Abstract

Introduction

Methods

Abstract

Results

What’s least important? Discussion – except limitations

Interpretation (Spin)

Discussion

Additionally, the top tips from Ellen Weber (@emjeditor) that I recall include:

  1. Avoid the phrase “little is known”. I get the sense this is A “DO NOT COLLECT 200, MOVE DIRECT TO JAIL” type phrase.
  2. Make sure you include in your results:
  • Who you studied the flow chart of eligibility, exclusion and follow up
  • A “Table 1” for overall characteristics
  • Tables and figures for raw data regarding primary and secondary outcomes before the use of statistical tests
  • Confidence intervals when reporting results from hypothesis testing
  1. Pitfalls include:
  • Failure to describe the sample
  • Failure to show raw summary data before the statistical analysis
  • ‘Over-statisticalizing’ a simple study
  1. In your discussion:
  • Use short paragraphs to summarise your results
  • Ensure you place the study and results in context
  • State the implications of the results and the limitations of the study
  1. Additional editors “Pet Peeves” to avoid are shown below:

The #EMTA17 Research Panel

Having first heard Professor Rick Body present at the Royal Society of Medicine EM Seminar in January 2017, we were keen to approach him to talk at the EMTA17 Conference. He had spoken so eloquently and passionately about the management of risk when looking after patients, something that fundamentally cuts to the heart of what we do in EM, that we were keen to hear more. This developed into a “Research Panel” including Professor Tim Harris and our newest RCEM Professor, Dan Horner.

The panel group generated much discussion and real debate in the room, during the breaks and on social media. What was most striking from all three of our Professors was how none of them had set out on a career in academic medicine from the very beginning of their training. It had evolved from interests in wanting to answer questions regarding the right thing to do for direct patient care. This is reassuring; there’s a researcher in all of us.

‘Anyone can do it’

Professor Rick Body (@richardbody) described the difference between primary research (a new study) and secondary research (looking at what others have done). He emphasised how secondary research need not be a full meta-analysis but can lead to a “BestBet” or Consensus Opinion (or even just completion of your CTR or evidence appraisal for your QIP). It can be about answering a focused, relevant question with pragmatic answers hence the birth of BestBets3. Rick encouraged the audience to consider developing a PICO question, do a literature review, critically appraise the relevant papers and summarise the findings then simply fill in the gaps on the template4. He enthused that it can change clinical practice and cited his example of “Is oxygen needed in acute MI”: a review of 70 studies that showed no benefit of oxygen5 – a practice changer! Rick really did inspire us, reinforcing the fact that anyone can do research and that it can change clinical practice in EM

‘Good medicine is good research’

Professor Tim Harris emphasised how research is about improving patient care. We need inquisitive minds to develop questions and then the studies need to be big enough to accurately measure absolute risk reduction. Audits rarely change clinical practice if only there was a way for all that effort from trainees to be centrally used to improve patient care! He also gave us the background to his route of training abroad and including academic work along with his travelling. He was an advocate that “good medicine is good research” and that the demands of the EM shop-floor work (short patient interactions and rapid decision making) can be balanced with the long term ambition of clinical research, giving a varied career and reducing burnout.

‘If Carlsberg did research.’

Professor Dan Horner talked about how there were RCEM proposals for a Trainee Emergency Research Network (TERN).

Dan was keen to get us thinking about “how we could do research“. Research active institutions6 have better clinical outcomes. The theories behind this hypothesise that it is due to several interrelated factors: nurturing a culture of questioning, inquisitive minds, self-motivation and persistent questioning of both evidence and authority based practice. Given that we have over 40,000 patients attending Type 1 EDs each day7– we are actually in a unique position to do research, and to do it quickly, if we have a national research network looking to all answer the same question. He emphasised the tremendous power in collaboration and the impact, meaning and reward such a project could have for both trainees and patients.

TERN will aim to set strategy, create opportunity and provide infrastructure to help trainees become involved in research projects. Further discussion over whether involvement in research could be an equivalent alternative to audit on ARCPs is already being questioned8, as is the idea of protected time within training for research.

Research: a vital foundation for EM care.

Every Major Trauma Centre is research active, yet only 70% of Type 1 Emergency Departments are engaged, even though evidence suggests that hospitals involved in research trials have better outcomes6. This resonated with me – anecdotally I have observed the differences in care given in hospitals that are research active and those that aren’t. Far from being an extra hoop, or the final straw that breaks the camel’s back, I have come to believe it really is a vital foundation for EM care that we all become involved in research to help improve clinical outcomes for our patients.

There are currently 77 open studies on the national portfolio and roles can include anything from simply being aware of the clinical trials that are recruiting in your department and notifying the research team, to becoming a Principal Investigator in your ED or over time developing your own idea and applying for funding as the Chief Investigator of a multi-centre study.

RCEM Study Days

There is no time limit to when you can start become involved in research. You don’t need to have an academic foundation post, or an academic clinical fellow post or a PhD. One of the Principal Investigators of the Year presenters, Dr Caroline Leech (@LeechCaroline), at the annual RCEM Clinical Studies Group Day9in January 2018 explained her inspirational journey of bringing research into both her ED and her PHEM work as a full time clinician it could be you winning this award one day!

Following the clinical studies group day was the RCEM Academic Trainees Day9 – an annual event which is open to non-academic trainees too. It was impressive to hear the research projects already completed or underway by EM trainees and gave an opportunity to make contacts, share ideas and capitalise on that enthusiasm.

TERN

The Trainee Emergency Research Network (TERN) officially launched at EUSEM. This is a network for trainees, run by trainees which aims to demystify and increase engagement with research. If you are interested in becoming involved, you can still register your details online at RCEMLearning or contact our inaugural TERN Fellow, Dr Tom Roberts, at TERN@rcem.ac.uk or follow him on twitter @TERNfellow.

After that, if you want to become involved in research the first proactive step would be to complete your Good Clinical Practice training here11 or here12 which is mandatory for all clinicians involved in recruiting into clinical trials.

Alternatively, you can apply to present a research idea at the Research Session at the EMTA Annual Conference (#EMTA18) in Cardiff on 27-28th November 2018. The deadline for abstract submissions is Thursday 13th September 5pm, and more details can be found here13 or by following @EMTAevents on twitter.

Blue Sky Thinking.

Daring to dream. So as a speciality, where do we want EM research to be in the future? How does it need be to help provide robust evidence to ensure the best care possible for the patients that present to both our departments as well as those looked after in the pre-hospital environment? Imagine if we were all working with an EM consultant body where we had at least one Professor of EM, not the 16 we reportedly have nationally.

It would also be amazing if there were opportunities for all grades to become involved with research and to tackle the key priorities14 established by the James Lind Alliance15. For example:

  • Foundation, core and higher academic posts available in all EM departments
  • Junior and Senior Clinical Fellow posts that contain a proportion of time for research activities.
  • Non-academic trainees having allocated SPA time that they could choose to use to do research activities.

Over the past few years there has definitely been a paradigm shift for me about research. I view it now as the vital foundation for everything we do to look after patients, not the proverbial straw that breaks the camel’s back because there is “one more box to complete” for the ARCP. I am excited that TERN is already making opportunities for EM trainees to become involved in research much more accessible, with time-efficient impact for improved patient care. As an RCEM initiative, with collaboration and buy-in from RCEM Learning, expect to see more articles and blogs that help demystify research, make options for engagement clearer and provide educational support for all of us working in EM. This can only be good for us, and for our patients.

Dr Carrie Thomas

ST4 in Emergency Medicine, South London. #EMTA18 Annual Conference Lead,

EMTA committee representative to TERN, TERN executive committee chairperson.

References/links:

  1. http://www.smartsurvey.co.uk
  2. http://pmj.bmj.com
  3. bestbets.org
  4. https://bestbets.org/database
  5. https://bestbets.org
  6. http://journals.plos.org
  7. http://www.rcem.ac.uk
  8. http://blogs.bmj.com/emj/2018/01/31/the-role-of-research-in-emergency-medicine-training/
  9. http://www.rcem.ac.uk/RCEM/Events
  10. https://docs.google.com
  11. https://www.rcem.ac.uk/RCEM/Quality_Policy/Professional_Affairs/Research/RCEM/Quality-Policy/Professional_Affairs
  12. https://learn.nihr.ac.uk
  13. http://www.emtraineesassociation.co.uk
  14. http://stemlynsblog.org
  15. http://www.jla.nihr.ac.uk

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2 Comments

  1. kandaratnami5783 says:

    Useful

  2. ramadanm686 says:

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