Does everyone need research training?

For reasons that still make me too cross to mention (sorry if you’ve been on the receiving end of one of my rants over the past week…), I’ve been thinking a lot about the academic training programme for the foundation years.

And then I read Daniel Lumsden’s piece in the RCPCH bulletin this month

http://www.rcpch.ac.uk/system/files/protected/news/RCPCH_Newsletter%20Summer%202013_for%20web.pdf

As I’ve read it, his point is that all trainees should have an understanding of research in order to be able to deliver the best care to their patients, and ensure the successful delivery of research projects.

I’m really not going to argue with that.

What bothers me most is what this concept of “understanding research” actually means.

A few months ago, I was asked by a colleague for some help in critiquing a paper for journal club.  Her problem? She didn’t understand the statistical tests that were being used, and thought I might be able to help.  Of course I couldn’t: I’ve never understood statistics before (I’m one of these people that has a notebook with the definitions of sensitivity and specificity written down…); I certainly wasn’t going to understand some convoluted test involving curves and words I’d never heard of before.

What’s more, I didn’t need to know.  It didn’t take long to work out that this paper (no naming and shaming I’m afraid!) was reporting a study that was badly designed, and that had chosen an inappropriate methodology to answer their research question.  None of that required an in-depth knowledge of statistics.  But it did require a basic understanding of research methods and purpose.

Now, I don’t think that most “grown-up” researchers can argue about Popper or post-modernism in research.  But maybe that’s part of the problem.  Our research training is organised and structured by scientists who structure their research in a particular way.  We understand about randomised controlled trials, but less about good epidemiology.  We understand chasing a single “truth” more than we appreciate what that truth means.  We’re more au fait with numbers than people.

Health services research, in all its unwieldy complexity, is a closed book to most.  Restructuring a service, a clinic, an outreach group is going to have more immediate impact on our patient care than the outcomes of a phase 1 trial.  But how many of us appreciate how to appraise this, or can critique a paper on this kind of topic?

Understanding the research methodology is essential to understanding research.

I’d go further.  I think that we all need an understanding of the history of research, and to understand why our standards have developed in the way they have.  We need to accept that there are different schools of thought; that not all research is hunting for a single truth; that generalisability isn’t the goal of all studies; that population statistics are applicable only to that population; that opinions & beliefs have an impact on which research questions are asked (and which are funded).

Only if we appreciate these things (and I think it would take a lifetime to understand them properly) can we spend time thinking about the fine detail of statistical tests.  Without understanding why a study has been designed in a certain way, how can we possibly hope to critique the fine detail?  There is simply no point looking at the p-value of a study where the question is irrelevant.  Using the wrong statistics might get you the wrong answer from the data you have available. Asking the wrong question renders that data meaningless, regardless of the tests you apply to it.

If the Keogh report is right, and junior doctors are “the clinical leaders of today”, then we need to understand the systems that we work with.  Research training needs to move on from the days of RCTs, and embrace the complexity of structural change.  It’s a big ask: this is complex, involves people and systems.  There aren’t simple designs or answers.

But the principles are the same regardless of the research approach: what you’re asking is important; how you answer it is important.  Realising that the answer you get at the end depends on the question you ask is something that applies to all forms of research.

Ultimately, understanding this makes us better doctors. I think it goes a long way to making us better researchers too.

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There’s no EWTD in research…

Another one of those things that I’m sure I was told before I started, but didn’t really sink in.

A few days ago, I had a weekend off.  I work part-time, so there are quite a few weekends that aren’t rota’d for work, but that’s really not the same as having a weekend off.   I went to the cinema for the first time in a year (I love minions!!), somebody cooked me a lovely dinner, I met a really good friend for coffee, and had met a really interesting girl for drinks.  It was a lovely weekend.

And in between all of those things, I read the papers for a BMA meeting this week.  I updated a couple of searches for my PhD.  (I even logged into e-portfolio, but couldn’t quite face it.  That’s one for the train on Friday night *sigh*).  My quiet drink on Sunday night generated a 12 item job list, and a Monday morning full of e-mails – I am still so cross, it’s going to have to wait until I’ve calmed down before I comment on that.

That’s my weekend off.

And I am reminded of something I heard at the BMA COMAR a few months ago: there’s no EWTD in research.

I carry my laptop with me everywhere I go.

I check e-mails, conference dates, social media for the PhD (#patientsafety, very useful, geeky though that sounds…).  Running out of data allowance on my phone sends me into a panic. I choose where I have coffee based on their internet access and my ability to fire off a few e-mails before I meet my friends.

It’s probably the least efficient way of working I could possibly have come up with.  (As evidenced by walking into the University on Monday morning, and despite spending most of the morning sending e-mails and trying to call the Deanery, I still managed to write 3000 words on the PhD).

So, next weekend, I’m going away.  Without my laptop.  For a whole weekend of sitting on the grass, listening to music, and eating cheese and cake.

Hopefully, that might re-energise me enough to tackle R&D…. hopefully.

I never wanted to do research…

Sometimes I wonder how I ended up here, doing this job.  I reiterate: it’s the best job in the world, and I love it.

But this is definitely not what I had planned for my life.

I never wanted to do research: this is completely true.  And I don’t just mean that I was ambivalent about it, or thought I’d have to do a bit to get ahead in my career.  I never wanted to do any research.

At all.

Ever.

And here I am, voluntarily extending my CCT date by at least 2 1/2 years (probably more), to build my own little niche  in a research field that confuses my medical colleagues, and that I don’t have the expertise to understand the background knowledge of as well as my university peers.

I never wanted to do research.

I remember meeting my first clinical academic: a fellow in renal medicine.  I was on my first clinical firm, at a busy inner-city London teaching hospital.  It was an old-fashioned, firm based medical student attachment, and I loved it.  I knew this was where I belonged, and who I wanted to be (not the renal bit).  The SHOs were slick, the SpRs were knowledgeable, the consultants seemed like gods (in fact, I think they may have been).  They expected a lot from everyone on the firm, and that included from their students.  It was amazing…

But within two days of being there, I could tell there was something different about the research guy.  He was no good with patients.  He was no good clinically (I was better at venepuncture than he was by the end of my second week – and I’m really not that good at practical skills).

I wasn’t interested in cause and effect.  I didn’t even consider that the two might not be related.  As far as I was concerned in my highly experienced, all of 2 weeks on clinical firm, self-assured 3rd year wisdom, doing research meant sacrificing my clinical ability.  That, quite simply, was not an option.

But slowly… very slowly… I got sucked in.

First there was the teaching, and the SSC, and the conference presentations that went with that.  Quite a big deal for a student, but still peripheral to my “real” life.

Then there was the BMedSci – purely to make me more competitive for the clinical jobs. Naturally

Then the academic foundation job – because how else was I supposed to guarantee a paediatrics job going through MTAS?  Sure, it meant moving away from the best city in the world (I’m not going to invite the torrents of criticism by specifying, but if you know me at all, you’ll know where I’m happiest!).  It started building up, and suddenly I was applying for an ACF job; staying in the Midlands….

Eventually, last year, I caved in…

I think I want to do research *gulp*

There. I’ve said it now.

Split personalities

I was trying to explain what I do to a new friend (not another medic).

I ended up describing myself as being a split personality: PhD student on Mondays & Tuesdays; NHS trainee Wednesday to Friday; and a variable mixture of the two of a weekend. (The reality of course is that it’s much closer to three jobs, because of all the other research stuff. And the admin, and emails, but I was trying to keep it simple… Supposedly, there’s a personal life in there too. Somewhere…)

This is how I’ve always approached it: two (or more) separate parts to my life and work. Separate jobs lists. Separate timetabling.  Separate persona…Basically, trying to live separate lives within my one, over-crowded life.  I like the sense of identity I get from being this different people (I love being part of the NHS, being part of this amazing organisation where thousands of people come together to care for someone; being that tiny cog in a big wheel)
One of the things I’ve really struggled with is trying to be all of these things, and deal with them separately. When I’m doing one or the other, I’m fine: I can latch on to that identity.  I can be the paeds SHO (except that now I have to try and be the reg!); I can be the researcher or the student; but swapping from one to another is hard.  Before, I worked in blocks: 6 months of research before going back into full-time clinical. Maybe the odd locum shift now and then to keep my hand in, but nothing with continuity.  I could just go in, do my job, and leave.  Except… except I hate working like that.  That’s not why I went into medicine; it’s definitely not why I became a paediatrician.  So, I throw myself into my research.

And when I’m on a clinical block, I throw myself into my “proper” job: being a doctor.
Underneath it all I’ve realised: I’m a paediatrician.  That’s what makes my heart sing.  It’s the moment when a child’s wheeze is clear enough that they run around the playroom; it’s when your lethargic patient wakes up enough to try and kick you while you do their bloods; it’s when your head is splitting because you’ve done a 12 hour shift with no food or drink and the sound of a child singing the same song over and over and over in the playroom sounds like music (Slight digression: Sir Thomas Beecham – I think – on marching bands: “All very well in their place, which is 5 miles away and marching in the opposite direction”.  I feel some sympathy with this, especially when the migraines kick in).

I’ve been trying to be an academic.  And I’ve been trying to be a paediatrician.  And trying to be both separately is tearing me apart.

Can I be both? or do I have to choose? or do I just keep going and hope I learn how to make it a little easier and still get through to a PhD and CCT

Who knows?