– Research –
Robert Frykberg,
DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage |
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People pay a lot of lip service to "research." Especially when we all get busier than we ever dreamed of being. Busy-ness is good by all means, but can get in the way of progress. When you are a Resident, your primary focus is to obtain the requisite number of surgical cases to fulfill the requirements for your program. In addition, there are numerous other requirements that must be satisfied in order to graduate and move into practice. And once in practice, the driving motivation is to build it up to the point that you can be busy and achieve some semblance of financial security. So, with all the attention paid to surgical cases and the demands of subsequent practice, where does research fit into this scheme and is it something that you really need to be concerned with?
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The answer is an unequivocal “yes”! First of all, you should already know that research is a required component of your residency training. Every resident in every CPME approved residency is required to participate in at least one research project. Of course, there is latitude in this requirement that enables you to choose the type of research project performed, as well as the subject of interest. This often takes the form of case series investigations and subsequent submissions as posters and the manuscripts for publication. Although this is considered to be low-level research, it has value above and beyond the fulfillment of a requirement. As I tell my own residents, it gets them away from ESPN and Facebook long enough to do something productive in their “off” time. At the very least, the development of even a simple research protocol trains one to investigate the literature on the topic of interest and critically appraise the current state of knowledge. With a focus on the anticipated research, the prospective researcher must fine tune their thinking, not only to develop the research question, but also the methodology necessary to obtain the desired (or expected ) outcome. Does one require an experimental design, a case series, a case-control study, a retrospective cohort study, prospective cohort study, or a double blinded randomized controlled trial (RCT) to answer the research question? If you are unfamiliar with the aforementioned study designs and the differences between each, another opportunity therefore presents itself to you in order to answer that very specific question.
"...the credibility of our profession will be determined by the credibility of our literature." |
Once you investigate the differences in each design, you can sharpen your research skills by making an informed decision as to which one most suits your needs. With the decision made, you must then determine the sample size needed, the availability of enrollees, inclusion criteria, exclusion criteria, time frames, and anticipated methods of research analysis. Should you use non-parametric methods because of small or skewed data sets? Is a student’s t-test appropriate or is a Wilcoxon Rank Sum test most appropriate for analyses? What will be the primary outcome measure (dependent variable) and which will be the explanatory (independent) variables of interest? What comparisons should be made to determine if any associations are present between the outcome measure(s) and the explanatory variables? Is a Chi-squared test appropriate to determine significance or is a Fisher’s Exact test necessary due to small cell sizes? Should you look for Odds Ratios or Risk Ratios or Hazard Ratios? What is the best way to obtain such measures of association? Is Logistic regression the best way to determine the Odds Ratios (OR) or will Mantel-Haentzel Chi squared tests provide equally robust analyses? What are the potential confounders in these analyses? How should you proceed with multivariate analysis and why should this be important to explain any perceived relationships? Is it important to provide 95% Confidence Intervals (CI) instead of simple p-values? Can one determine significance of the associations based on 95% CI alone? These questions must always be considered in the design of any study and certainly during the analysis of data obtained. If such terminology is completely foreign to you (as it once was to me), I submit that you are unprepared to be educated consumers of the medical literature.
"Physicians need to understand the validity of articles published in the journals. It's not evidence just because it appeared in print." |
Why is all of this important to you? Because of the need to understand the validity of articles published in the journals that you read. You must decipher the good from the bad, the useful from the unimportant. You must be familiar with a basic level of biostatistics in order to fully comprehend the value (and significance) of the articles that you read – and read you must if you are to keep up with ever changing technologies, pharmacology, and the epidemiology of diseases. It is my contention that by engaging in research as described above, you will better be able to comprehend the results of published studies. Let’s face it; new research is the lifeblood of Medicine and Surgery.
"It is my contention that by engaging in research ...you will better be able to comprehend the results of published studies." |
Consider taking an active role in research, even after you leave your training programs. Consider the possibility of doing a postgraduate Fellowship in research. Consider getting an advanced degree to assist in this regard, such as an MPH or PhD. What better way to expand your horizons and brighten your future? Consider the contributions that you might be able to make to your profession by taking a career path in which a primary focus is on clinical research. Two names come to mind that exemplify the best clinical researchers that we have in Podiatry: Lavery (MPH) and Armstrong (PhD). Although not alone among a growing cadre of Podiatric researchers, these two colleagues have contributed more to the field of foot and ankle, as well as the diabetic foot, than any other researchers in Podiatry to date. They are both highly respected around the world for their contributions and they have served us well as Ambassadors for Podiatry. You can do the same if you have the mindset and have the discipline to achieve similar accomplishments. Challenge yourself and in the spirit of that famous Army slogan, “Be All That You Can Be”. You won’t regret it!
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Best regards,
Robert Frykberg, DPM, MPH
PRESENT Editor,
Diabetic Limb Salvage
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