How to be a Successful How to be a Successful Resident Researcher Resident Researcher

Achilleas Thoma, MD, MSc, FRCSCAchilleas Thoma, MD, MSc, FRCSCDivision of Plastic SurgeryDivision of Plastic Surgery

Surgical Outcomes Research CentreSurgical Outcomes Research CentreDepartment of Clinical Epidemiology Department of Clinical Epidemiology

and Biostatisticsand Biostatistics

CORE Aug 6 2008CORE Aug 6 2008

Learning ObjectivesLearning Objectives

1.1. The process of pairing with a The process of pairing with a supervisorsupervisor

2.2. How to start your research projectHow to start your research project

3.3. Determining a timeline for project Determining a timeline for project completion completion

4.4. Tips that help keep things on track Tips that help keep things on track

Why do Research?Why do Research?

• Because it is a requirement for your Because it is a requirement for your programprogram

• Resident research day is fast Resident research day is fast approaching and you are expected to approaching and you are expected to presentpresent

• You want publications to build your You want publications to build your CVCV

Resident

Why do Research?Why do Research?

• You have the passion to improve your You have the passion to improve your knowledgeknowledge

• You want to apply for a MSc or PhD You want to apply for a MSc or PhD program through the Clinical program through the Clinical Investigator Program or HRM ProgramInvestigator Program or HRM Program

• You have the passion for scientific You have the passion for scientific inquiry and to advance your specialtyinquiry and to advance your specialty

Resident

Types of ResidentsTypes of Residents

1.1. ““Talkers”Talkers”

2.2. ““Doers”Doers”

Which are YOU?Which are YOU?

Resident

Resident Research ProductivityResident Research Productivity

• ““Talkers” have no publications by the Talkers” have no publications by the time they have completed their time they have completed their residency programresidency program

• ““Doers” will have published at least 1 Doers” will have published at least 1 article / year in their residency program article / year in their residency program and will have presented their work at and will have presented their work at their national society meetingstheir national society meetings

Resident

Prerequisites for SuccessPrerequisites for Success

• PassionPassion

The emotion of feeling very The emotion of feeling very strongly about a subject strongly about a subject

• InitiativeInitiative

The ability and tendency to initiate: to The ability and tendency to initiate: to start an action and maintain start an action and maintain momentum on the projectmomentum on the project

Resident

1. The Process of Pairing 1. The Process of Pairing with a Supervisorwith a Supervisor

Finding Your SupervisorFinding Your Supervisor

1.1. Match your research interests with Match your research interests with supervisor expertisesupervisor expertise

2.2. Do some “detective work” on the Do some “detective work” on the supervisorsupervisor

3.3. Read the supervisor’s publications Read the supervisor’s publications and be familiar with his/her workand be familiar with his/her work

4.4. Ask if she/he available to meet with Ask if she/he available to meet with you after 5 pm / the weekendsyou after 5 pm / the weekends

1. Supervisor

Expectations for SupervisorExpectations for Supervisor

1.1. Supervisor is available to meet in the Supervisor is available to meet in the off hours (i.e. after 5pm / weekends)off hours (i.e. after 5pm / weekends)

2.2. Supervisor has done some researchSupervisor has done some research

3.3. Supervisor is willing to provide timely Supervisor is willing to provide timely feedback and guidance on the feedback and guidance on the research projectresearch project

4.4. Supervisor is willing to devote the Supervisor is willing to devote the time and energy to assist youtime and energy to assist you

1. Supervisor

Expectations for ResidentExpectations for Resident

• Be a “doer” rather than a “talker”Be a “doer” rather than a “talker”

• Resident initiates weekly meetings and Resident initiates weekly meetings and gives progress reports on his/her gives progress reports on his/her research projectresearch project

• Keeps minutes of discussions and Keeps minutes of discussions and action plan after every meeting and action plan after every meeting and gives copy to supervisorgives copy to supervisor

• Knows the basics of research designsKnows the basics of research designs

1. Supervisor

Roles of a SupervisorRoles of a Supervisor

• ResourcesResources

• OpportunitiesOpportunities

• AdviceAdvice

• ProtectionProtection

1. Supervisor

ResourcesResources

• Office space and supplies (e.g. Office space and supplies (e.g. photocopying, internet access)photocopying, internet access)

• Secretarial and administrative supportSecretarial and administrative support

• Financial support to attend meetings, Financial support to attend meetings, conferences, coursesconferences, courses

• Research coordinator support Research coordinator support

1. Supervisor

OpportunitiesOpportunities

• Join ongoing research projectsJoin ongoing research projects

• Help review manuscripts and grant Help review manuscripts and grant applications applications

• Attend meetingsAttend meetings

• Learn about Research Ethics Review Learn about Research Ethics Review CommitteesCommittees

1. Supervisor

AdviceAdvice

• Methodological challenges of projectMethodological challenges of project

• Pros and cons of working with Pros and cons of working with particular collaboratorsparticular collaborators

• Time managementTime management

1. Supervisor

ProtectionProtection

• Opportunities to practice Opportunities to practice presentations and defend your presentations and defend your conclusions in a friendly atmosphere, conclusions in a friendly atmosphere, before presenting at a national before presenting at a national meeting. meeting.

1. Supervisor

2. How to Start your 2. How to Start your Research ProjectResearch Project

Starting your Research ProjectStarting your Research Project

• Is the question you are trying to answer Is the question you are trying to answer in your research project in your research project clinically clinically importantimportant or or trivialtrivial??

• Distinction between the trivial and Distinction between the trivial and important questions is not that easy…important questions is not that easy…

the answer lies in scholarshipthe answer lies in scholarship

2. Organizing Research

Reasons to Pursue a Research QuestionReasons to Pursue a Research Question

• Intervention is novel Intervention is novel • Intervention consumes large health Intervention consumes large health

care resourcescare resources• Controversy on the effectiveness of Controversy on the effectiveness of

the novel procedurethe novel procedure• Large cost difference between 2 Large cost difference between 2

prevailing interventionsprevailing interventions

2. Organizing Research

Starting your Research ProjectStarting your Research Project

• You have to be familiar with the You have to be familiar with the boundary of knowledge on the subject boundary of knowledge on the subject

• To do this you have to first perform a To do this you have to first perform a systematic review of the subject (i.e. systematic review of the subject (i.e. thorough review of the literature)thorough review of the literature)

2. Organizing Research

Research is an Iterative ProcessResearch is an Iterative Process

2. Organizing Research

SupportSupport

• Collaborate with other residents / Collaborate with other residents / medical studentsmedical students

2. Organizing Research

Initial Groundwork for Research Initial Groundwork for Research Question FormulationQuestion Formulation

1.1. PlausibilityPlausibility

2.2. FeasibilityFeasibility

3.3. SupportSupport

4.4. ResourcesResources

2. Organizing Research

PlausibilityPlausibility

• Is the question answerable?Is the question answerable?

• Must have a thorough understanding Must have a thorough understanding of the anatomy, biology, physiology of the anatomy, biology, physiology and prevalence of the problemand prevalence of the problem

2. Organizing Research

Plausibility ExamplePlausibility Example

• It is not plausible to examine the It is not plausible to examine the outcomes of reconstruction of the outcomes of reconstruction of the congenitally absent ear in a RCT congenitally absent ear in a RCT comparing the Nagata technique with comparing the Nagata technique with the “genetic engineering method” the “genetic engineering method”

• The genetic engineering methods are The genetic engineering methods are not advanced at this point in time to not advanced at this point in time to regenerate an acceptable earregenerate an acceptable ear

2. Organizing Research

FeasibilityFeasibility

• Whether the study design we choose Whether the study design we choose is one that can potentially answer the is one that can potentially answer the research question research question

• Best study design depends on the Best study design depends on the question being askedquestion being asked

2. Organizing Research

Feasibility ExampleFeasibility Example

Research Question:Research Question:

• Is the supramicrosurgical reconstruction with Is the supramicrosurgical reconstruction with a periumbilical abdominal flap is superior to a periumbilical abdominal flap is superior to the deep inferior epigastric perforator (DIEP) the deep inferior epigastric perforator (DIEP) flap in breast reconstruction ?flap in breast reconstruction ?

Possible barriers:Possible barriers:

• We don’t know how to transfer a flap with a We don’t know how to transfer a flap with a 0.8 mm luminal diameter of the vascular 0.8 mm luminal diameter of the vascular pedicle pedicle

• We don’t have the required instruments We don’t have the required instruments

• QOL scales may not be sensitive enoughQOL scales may not be sensitive enough

2. Organizing Research

FeasibilityFeasibility

Choosing a Study DesignChoosing a Study Design

• Simple Studies (i.e. Case series, Cohort)Simple Studies (i.e. Case series, Cohort)– If little is known on the topic, or there are If little is known on the topic, or there are

big gaps in knowledgebig gaps in knowledge

• RCTRCT– When a novel surgical technique entered When a novel surgical technique entered

the main stream of surgery and challenges the main stream of surgery and challenges a prevailing one a prevailing one

2. Organizing Research

Feasibility ExampleFeasibility Example

Research Design:Research Design:• RCT to determine whether smoking affects RCT to determine whether smoking affects

the short-term survival of replanted digitsthe short-term survival of replanted digitsBarriers:Barriers: • Ethically, we cannot randomize patients to Ethically, we cannot randomize patients to

either Group A: continue smoking or either Group A: continue smoking or Group B: non-smoking after replantation Group B: non-smoking after replantation of digits. of digits.

• For questions of harm, appropriate study For questions of harm, appropriate study designs include case-control studies and designs include case-control studies and cohort studiescohort studies

2. Organizing Research

Feasibility – ExampleFeasibility – Example

Research Design:Research Design:• RCT comparing the use of intermittent lower RCT comparing the use of intermittent lower

extremity pump vs. low molecular heparin in extremity pump vs. low molecular heparin in preventing fatal pulmonary embolism in preventing fatal pulmonary embolism in cosmetic abdominoplasty. cosmetic abdominoplasty.

Possible Barriers:Possible Barriers:• Fatal pulmonary embolism in cosmetic Fatal pulmonary embolism in cosmetic

abdominoplasty is a very rare event. abdominoplasty is a very rare event. • As the frequency of the ‘end points” is a critical As the frequency of the ‘end points” is a critical

factor in the sample size calculation, the rarity factor in the sample size calculation, the rarity of the target event means that the investigator of the target event means that the investigator will require a sample size measured in will require a sample size measured in thousands of patients!thousands of patients!

2. Organizing Research

ResourcesResources

• Financial resourcesFinancial resources

Think of the budget and the details Think of the budget and the details that go with that!that go with that!

• Choose a supervisor who has research Choose a supervisor who has research coordinator supportcoordinator support

2. Organizing Research

Item Year 1 Year 2 Justification

Research Assistant $26.00 / hour + 35% fringe benefits 16 hours / week for 2 years

$29203.20 $29203.20 A research assistant is required to coordinate this project. Duties will include helping to screen and consent patients, ensuring that the case report forms are completed by participating surgeons, administering the quality of life questionnaires to patients, data entry, and assisting with the costing and analyzing of the data.

Statistician/data analyst $50/hour for 75 hours

$0.00 $3,750.00 A statistician/data analyst is required to provide methodological consultation throughout the trial and to analyze the data at the end of the trial.

Economist Consultation$50/hour for 20 hours

$0.00 $1,000.00 An economist is required to provide methodological consultation throughout the trial and to help cost the data at the end of the trial.

Photocopying of case report forms and quality of life forms

$725.00 $725.00 We will need to photocopy the case report forms and the quality of life forms.

Office supplies $250.00 $250.00 We will require to following office supplies for this project: envelops, papers, folders, and CDs for data storage.

Health Utilities Index.

$4000.00 $0.00 There is $4000 administration fee to use this questionnaire

Mailing of quality of life forms

$200.00 $200.00 We anticipate that we will need to mail multiple quality of life questionnaires to each patient to help ensure complete follow up.

Total budget$ 69 506.40

Year 1$34 378.20

Year 2$35 128.20

Forming the Research QuestionForming the Research Question

• You have an idea, the necessary You have an idea, the necessary support and resources now you need support and resources now you need to transform your research idea into a to transform your research idea into a well built clinical questionwell built clinical question

2. Organizing Research

Background QuestionsBackground Questions

• Ask for general knowledge about a Ask for general knowledge about a surgery problemsurgery problem

• Have two essential components:Have two essential components:

1.1. A question root (who, what, where, A question root (who, what, where, when, how, why) with a verbwhen, how, why) with a verb

2.2. A disorder, or an aspect of a disorderA disorder, or an aspect of a disorder

i.e. What complications can occur with i.e. What complications can occur with the ECTR?the ECTR?

2. Organizing Research

Foreground QuestionsForeground Questions

• Ask for specific knowledge about managing Ask for specific knowledge about managing patients with a surgery problempatients with a surgery problem

5 essential components:5 essential components:

PPatient or problematient or problem

IInterventionntervention

CComparison intervention (if relevant)omparison intervention (if relevant)

OOutcomesutcomes

TTimeime

2. Organizing Research

Well Built Clinical QuestionWell Built Clinical Question

• PPopulation (patient)opulation (patient)

• IInterventionntervention

• CComparison (this is optional)omparison (this is optional)

• OOutcomeutcome

• TTime Horizonime Horizon

2. Organizing Research

Population (Patients)Population (Patients)

• How would I describe a group of How would I describe a group of patients similar to mine?patients similar to mine?

– Be brief and preciseBe brief and precise

i.e. i.e. All patients with clinical evidence All patients with clinical evidence of carpal tunnel syndrome confirmed of carpal tunnel syndrome confirmed with EMG and nerve conduction with EMG and nerve conduction studystudy

2. Organizing Research

InterventionIntervention

• Which main intervention, prognostic Which main intervention, prognostic factor or exposure am I considering?factor or exposure am I considering?

– Be specificBe specific

i.e. i.e. In ECTR, the Agee or the Chow In ECTR, the Agee or the Chow technique or extrabursal or intrabursal technique or extrabursal or intrabursal

2. Organizing Research

Comparative InterventionComparative Intervention

• What is the main alternative to What is the main alternative to compare with the intervention?compare with the intervention?

– Be specificBe specific

i.e.i.e. In OCTR, short incisions and long In OCTR, short incisions and long incisions, as these incisions allow one incisions, as these incisions allow one to visualize the median nerveto visualize the median nerve

2. Organizing Research

OutcomeOutcome

• What can I hope to accomplish, What can I hope to accomplish, measure, improve or affect?measure, improve or affect?

– Be specificBe specific

i.e.i.e.– Pain controlPain control– Return to work, ADLReturn to work, ADL– Improve Quality of Life (QOL)Improve Quality of Life (QOL)– Quality Adjusted Life Years Quality Adjusted Life Years

(QALYs)(QALYs)

2. Organizing Research

OutcomesOutcomes

• How will you measure them?How will you measure them?

• Who will measure them (think of bias Who will measure them (think of bias introduction)introduction)

• How often will you measure them?How often will you measure them?

2. Organizing Research

Time HorizonTime Horizon

• Appropriate time to measure outcomeAppropriate time to measure outcome

• 1 month post-op1 month post-op

• 6 months post-op6 months post-op

• 1 year post-op1 year post-op

• Long term >5 yearsLong term >5 years

• For the patient’s life?For the patient’s life?

• Short, intermediate, long term follow-upShort, intermediate, long term follow-up

2. Organizing Research

Time HorizonTime Horizon

Example:Example:

• Population --- chronic osteomyelitis of Population --- chronic osteomyelitis of tibia patientstibia patients

• Intervention ---free muscle flapIntervention ---free muscle flap

• Comparison --- free cutaneous flapComparison --- free cutaneous flap

• Outcome ---no drainage of pus from Outcome ---no drainage of pus from tibiatibia

• Time Horizon --- 2 yearsTime Horizon --- 2 years

2. Organizing Research

Framing the Clinical Problem Framing the Clinical Problem

PopulationPopulation Patients who have clinical symptoms Patients who have clinical symptoms of CTS and confirmed with EMG and of CTS and confirmed with EMG and nerve conduction studiesnerve conduction studies

InterventionIntervention Any ECTR techniqueAny ECTR technique

Comparison Comparison Any OCTR techniqueAny OCTR technique

OutcomeOutcome HRQL, cost (cost-effectiveness), HRQL, cost (cost-effectiveness), Return to work, PainReturn to work, Pain

Time horizonTime horizon Short term (6 weeks), long term (3 Short term (6 weeks), long term (3 years)years)

2. Organizing Research

3. Timeline for Completion3. Timeline for Completion

Research TimelineResearch Timeline

Formulation of Research Question &

Study Protocol

Development

Patient Recruitment; Data Collection

Data Analysis

Manuscript Writing

Present at Peer-

Reviewed Meetings

3. Timeline

4 Months4 Months 8 Months8 Months 1 Month1 Month 2 Months2 Months

Time ManagementTime Management

• Set a realistic goal for completion!Set a realistic goal for completion!

• The onus is on YOU!The onus is on YOU!

3. Timeline

Time Management!Time Management!

• The most important element of time The most important element of time management for academic success is management for academic success is setting aside time for your projectsetting aside time for your project

3. Timeline

Communication IssuesCommunication Issues

• You have to communicate and You have to communicate and negotiate with onsite clinical negotiate with onsite clinical supervisor ahead of time the time supervisor ahead of time the time required off your clinical duties to required off your clinical duties to perform your research projectperform your research project

• Need clear contract and understanding Need clear contract and understanding organized ahead of timeorganized ahead of time

3. Timeline

4. Tips for Success4. Tips for Success

Your SuccessYour Success

• Keep up the momentum!Keep up the momentum!

• Report progress weekly to your Report progress weekly to your supervisorsupervisor

• The onus is on you to keep the project The onus is on you to keep the project goinggoing

4. Tips

ExerciseExercise

Break into Groups by specialtyBreak into Groups by specialty

Design a clinically important research Design a clinically important research project in your specialty (based on project in your specialty (based on PICOT)PICOT)

ExerciseExercise

1.1. Who will be your supervisor will be and Who will be your supervisor will be and why?why?

2.2. What study design will you use to What study design will you use to answer your question?answer your question?

3.3. Provide a detailed budgetProvide a detailed budget

4.4. Discuss the feasibility of the project in a Discuss the feasibility of the project in a 5 year residency program5 year residency program

5.5. List 5 difficulties you will experience in List 5 difficulties you will experience in executing the projectexecuting the project