Nurturing a Research Mindset

Nurturing a Research Mindset

Raja Selvaraj, JIPMER

15 + 5 minutes

What this talk is about

Topic is open ended But I am specifically going to talk about research in the midst of a clinical practice Why it is necessary and how to cultivate it

The Clinician - Researcher dichotomy

I am a clinician, not a researcher
Busy practice with little additional time
Not necessary outside academic practice

Unhealthy dichotomy of clinician and researcher Usual excuse of the "non-research" clinician

There is an unfortunate division between research and clinical practice, which is not needed A scientific way of clinical practice needs a research mindset Research mindset doesnt necessarily mean doing research with an eye on publications Research is a way of clinical practice Research is not = publication

Why

Good Clinical practice is a form of research

Find best way to treat a patient (systematic review / metaanalysis)
Find reasons for gap between evidence and practice (implementation research)
Fill evidence gaps (Retrospective review of data / prospective study)
Help others learn from your experience (publish)

When done with a scientific approach, clinical practice recapitulates research studies

"Hidden" outcomes revealed by registries

Hidden outcomes can blur clinical judgement
Sudden deaths in patients post myocardial infarction
Mortality in RHD patients on anticoagulation

Do you only see the patients who come to see you Or do you make diligent efforts to follow up each patient? Our examples - RHD on OAC - deaths from major bleeds

Post MI, reduced LV function, sudden deaths

100 patients post MI

As an example of hidden outcome, take 100 patints post MI

At 1 year, Angina -> PCI

Some undergo PCI for angina

Angina -> CABG

Some undergo CABG

Worsen -> Death

A few worsen and die

Remaining on medical management

The remaining are on medical management The clinician does not see the 5 who dont come back Assumes that ischemia is the only important clinical problem

Sudden death. "Hidden" from clinician

These 5 have died suddenly. A preventable problem once we know it exists

How

Evidence based medicine

"Integrating individual clinical expertise with the best external evidence" - David Sackett

David Sackett - Father of evidence based medicine And that is what a research mindset is all about not practising clinical medicine in isolation

Stay Curious, Stay Disinterested, Stay Sceptical

Continue to be curious in medicine teaching, academics helps while looking at evidence, stay sceptical remember - always defend the null hypothesis

Maintain records

Handwritten records
Spreadsheets
Full fledged EMR

Maintaining records should be started from the beginning of the practice Use whichever method works

Quantify what can be measured

Qualitative information may be useful in situations
But quantitative information lends itself better to analysis
Key performance indicators

Promote research in medical curriculum

Undergraduates should learn research
Changing trend

Important so that research methodology is not alien to undergraduate students Now there are MBBS conferences, ICMR grants (STS) and institute grants (GJ STRAUSS) Important to mentor them

Examples

Records at JIPMER

Serves dual purpose Better clinical care to patients Availability of data for research

KPI for JIPMER EP

Sedation for EP procedures

Reuse of CIED

Computerized Heart Failure Clinic

Multi-disciplinary clinic for patients with heart failure
Computerised algorithm driven suggestions to promote evidence based rules
Limited clinic capacity
Options - First come, first serve / Historical controls / RCT

With plans to start a heart failure clinic and with limited capacity we opted for an rct to evaluate impact

Paul Wood 1907-1962

Paul Wood

Learn from meticulous and scientific evaluation of each case
- Described ihss without surgical / pathologic correlation
- Described acyanotic fallot
Measure everything
- Grading for effort tolerance
Maintain and collate data
- Graph of effort tolerance in ASD
Filter / sort
- Index cards with punch holes

Clinician - researcher ahead of his time

Known as an astute clinician taking tremendous interest in individual cases (in fact described diseases / phenomena based on single patients) also took interest in collating information

Rheumatic heart disease - AF and embolism

Paul Wood's system

Used cards for individual patient data Punched holes on top for variables Holes extended to edge when variable present Use a needle inserted into a hole to filter for that condition

And this is what I want to end with Because this is the epitome of good clinical practice with a research mindset And if he could do this in the 1950's, surely today we should be able to do much better

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Nurturing a Research Mindset Raja Selvaraj, JIPMER 15 + 5 minutes