Turning Clinical practice into Scholarship: Even without funding

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Turning Clinical practice into ScholarshipEven
without funding!

• Michele T. Pato, M.D.
• Associate Dean Academic Scholarship Professor of
  Psychiatry-Keck SOM-USC
• Center for Psychiatric and Molecular Genetics
• (adapted with permission,9/4/03, from Doing
  Research on a Shoestring Budget-
• M. Dewan, E. Silberman, M.T. Pato)

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Why Publish and/or Do Research?

• Satisfies your own curiosity
• Advances the field
• Improves patient care
• Advances your own career
• Gains you respect among peers colleagues
• A break from the routine-Burn Out prevention!
• Gives your parents,kids (and chair) something to
  brag about!

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Where do ideas come from?

• EXPERIENCE!!!!
• Patients
• Things that go right
• Things that go wrong, Side effects
• The unexpected
• Literature
• New findings
• Metanalysis
• Review articles
• Philosophical articles
• Colleagues (MD, Nurse,Psychologist,SW), students
  and friends
• At meetings
• On rounds
• Over dinner,At the coffee pot

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Research is good clinical care

• Turning a notion into research
• ASKING A QUESTION YOU CAN ANSWER WITH THE
  RESOURCES AT YOUR DISPOSAL

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Things youll need

• A question to answer
• A sample of subjects
• Something to measure
• A way to measure it
• A way to summarize and analyze your measurements
• A way to disperse you findings

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Things youll need-Elaborated

• A question to answer- A null hypothesis-(The So
  what test)
• A sample of subjects-(Generalizability)
• Something to measure
• an Outcome variable (dependent variable)
• Predictor variable (independent variables)
• A way to control interference (inclusion and
  exclusion criteria)
• A way to measure it
• Rating scales,
• Instrumentation-biologic, physical
• Outcomes and surveys
• A way to summarize and analyze your measurements
  (statistics)(S. Glantz- Primer Biostatistics)
• How many subjects do I need to say something
  significant- (POWER)
• A way to disperse you findings-(PublicationsGrant
  s)

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Ways to contribute to Your Field!

• Teaching-Self, Students, Colleagues (CME)-see
  online below
• Publishing- In the literature
• Letters to the editor- n of 1 studies
• Case reports
• Literature review
• Questionaire studies
• Chart review
• Think pieces
• Open clinical trials
• Hypothesis driven studies
• Case-controlCohort study, Randomized clinical
  trials, Biologic studies
• Publishing- On line
• Entrez-PubMed http//www.ncbi.nlm.nih.gov/PubMed
• AAMC education tools- MedEdPortal and IIME(
  Institute for Improving Medical Education)

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More on AAMC sites (Association American Medical
Colleges)

• MedEdPORTAL?-MedEdPORTAL is a Web-based tool that
  promotes collaboration across disciplines and
  institutions by facilitating the exchange of peer
  reviewed educational materials, knowledge, and
  solutions. The overall goal of MedEdPORTAL is to
  serve as a central repository of high quality
  educational materials such as PowerPoint
  presentations, assessment materials, virtual
  patient cases, and faculty development materials.
• Institute for Improving Medical Education-? IIME-
  The AAMC established the IIME to respond to
  concerns about the quality of U.S. medical
  education. The institute convenes expert panels
  to provide guidance on innovative approaches to
  educate doctors develop grant programs to
  provide support for development and
  implementation of innovations in education
  develop and disseminates position papers
  organizes policy forums to focus attention on
  specific issues and build coalitions of
  organizations willing to work toward change.

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Entering the Scientific Domain

• an individuals knowledge properly enters the
  domain of science only after it is presented to
  others in such a fashion that they can
  independently judge its validity
• Importance of skepticism in science

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Why publish?

• Reporting new scientific findings
• To warn or inform others of your experience
• Allows evaluation of results
• Places results in perspective against work in
  field
• Allows for replication of your work
• Credits other scientistsboth co-authors others
  in the field who have influenced work
• Establishes who is accepting responsibility for
  the work

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Jacob , 1988 The Statue Within, Basic Books Inc,
NY, NY

• Scientific writing transforms and formalizes
  research
• Scientific writing substitute(s) an orderly
  train of concepts and experiments for a jumble of
  disordered efforts In short writing a paper is
  to substitute order for disorder and agitation
  that animate life in the laboratory.

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A good hypothesis should be

• Internally consistent
• Provide accurate experimental predictions
• Unify disparate observations
• Have simplicity and elegance

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Using informed consent in Clinical setting

• Consider running your clinical practice from the
  beginning with a request to your patients to use
  clinical data in their chart for research in a
  conscientious, confidential, and ethical way.
• To monitor your own practices
• To improve your care of patients
• To contribute to the literature in your specialty
• ( all possible things to publish/report !!)
• HIPAA- Health Insurance Portability and
  Accountability Act

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Using Scholarship in becoming a Clinical Scholar?

• CriteriaFocus of Research is on application of
  clinical science to clinical care
• National reputation with innovation in clinically
  important research.
• Evidence that there is a theme of
  expertise-could be broader than tenure track
  faculty
• evidence of Excellence in SCHOLARSHIP and in one
  of two other areas (Teaching or Service)
• As with Tenure track this appointment must be
  granted at the university (UCAPT) level as the
  medical school level.

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Using Scholarship in becoming a clinical scholar?

• Demonstration of Scholarship includes
• Research that is widely recognized as making an
  impact in a specific area of medicine or science
• Continued productivity as first or senior author
  of important articles in high quality peer
  reviewed journals
• Success in obtaining peer reviewed funding
  especially from governmental agencies.
• More flexibility of Recognition and Funding for
  Clinical Scholar versus Tenure but excellence
  still required.

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Using Scholarship in the Clinical Educator track

• This non-tenure track still recognizes excellence
  but in the practice of Teaching and Leadership in
  major educational programs. Excellence includes
• Didactic clinical teaching evals
• Gaining educational grants
• Receipt local national awards and recognition
• Production publication teaching materials
  and methods - ie SCHOLARSHIP

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FYI information

• New Faculty and Staff Orientation Guide
  http//capsnet.usc.edu/ProfessionalDevelopment/Ori
  entationGuide/documents/NEO2006.pdf
• Faculty Handbook http//policies.usc.edu/facult
  yhandbook/
• Dental faculty promotion info is
  http//www.usc.edu/hsc/dental/dfa/documents.htm
• IRB- Internal Review Board http//www.usc.edu/aca
  deme/faculty/research/ethical_conduct/
• HIPAA-Health Insurance PortabilityAccountability
  Act http//www.usc.edu/admin/compliance/hipaa.htm
  l

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More to come

• Talk about specifics of
• Getting support without funding
• Writing for publication in small groups
• Informed consent

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Getting started without funding

• WHAT ARE YOU GOING TO STUDY?
• What do you need?
• Personnel-
• To do assessment
• To enter data
• To analyze data
• To Do clerical work
• Equipment
• Supplies
• Lab tests
• Subject payment

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Sources of Personnel without funding

• Secretaries
• Students
• PhD candidates - esp. psychologists
• Residents
• Med students
• Colleagues- MD, Nurse,Psychologist,SW
• Volunteers
• Research assistants on other projects
• So you only pay for the time you need

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Non-Monetary payment-Bartering

• Co-Authorship - paper or grant
• No cost Piggyback on another study
• (just agree to do the IRB paperwork)
• Analyze existing data
• Offer to teach in exchange for support
• Offer to do more clinical work in exchange for
  support ( but you have to make the time)
• Offer to help someone else in exchange
• Exchanging technical skills

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Small sources of money-Befriend grant/research
staff

• Seed money-( can be memorial award)
• Departmental
• Medical school
• Undergraduate med ed
• Graduate med ed
• Junior faculty awards
• Pharmaceutical companies-instead of pizza
• Foundation grants
• NARSAD(scz/dep), RWJ(hsrd), McArthur award(mood),
  Scottish Rite (psychosis),National
  organizations-OCD, Dep, ADAA
• NIH- small grants, first awards,
• Become a co-investigator or consultant

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Getting it into print!!

• Choosing the right journal
• Writers block- getting started
• Reviews and rejections

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Getting it into print!!

• Choosing the right journal
• What do they usually publish
• Following instructions
• Choosing the right length-
• Generalizability
• Scientific merit

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The purposes of allocating credit

• Acknowledges work of others
• Directs the reader toward additional sources
• Acknowledges conflict with other results
• Provides support for views expressed
• Places paper in broader scientific context

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Senior author and/orFirst author?

• Assumes responsibility for
• Validity of entire body of work
• Facilitating communication among co-authors
• Describing role contribution each co-author
• Logistics of manuscript submission
• Distribution of reprints
• Response to peer review comments
• Meeting requests to share material
• Responding to queries about the work
• Retention and storage of data

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Writing and Reviewing Having good friends and
enemies!

• Writers block- getting started
• Get something down.
• Polish the apple later
• Read it aloud
• Have others read it-friends and enemies
• Rejection and review
• Routine - 2 of publications accepted initially
  but 20-40 accepted on resubmission.
• Reviewers often dont agree
• One study 585 comments 42x agreed (Fiske and
  Fogg, 1985 Am Psychologist, 45,591-598)
• Remember reviewers are people just like you!
• Theyre not always right!
• They dont always get it!

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Common review criteria

• Try to be non-adversarial instead help author
  editor
• Evaluating the MERIT
• Clear statement of problem
• Appropriate literature citations
• Scientific merit and originality

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Review criteria cont

• Techniques and preparation
• Research designs and techniques appropriate
• Description and methods detailed enough to
  replicate
• Is data presently clearly and effectively
• Are interpretations sound,logical, clearly
  worded
• Is manuscript easy to read, grammatically correct
• Read title and abstract last!!
• DO THEY ADEQUATELY AND ACCURATELY REFLECT THE
  WORK?

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Informed consent

• A Necessary part of
• any Human Subject
• Research

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Informed consent is a process not a signature!

• And the process is ongoing for the entire course
  of the research AND Doctor-patient relationship

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Key elements of Informed Consent

• Facilitating a Free and Informed choice
• That it is research and what the research entails
• Risks and discomfort
• Benefits
• Alternative treatments
• Confidentiality
• Compensation
• Who to contact with questions
• Participation is Voluntary

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Problems with Informed Consent

• Limited by ability of patient to understand
  especially with regard to medical literacy
• Understanding the consent form seems Inversely
  related to ITS LENGTH!
• Average form written for 8th grade reading level
  but average literacy of population is 5th grade
  level.

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Waiving requirements for Informed Consent

• Even a waiver of written consent must be run
  through the IRB
• Studies that have no more than minimal risk of
  harm and no individual identifiers
• Examples include
• Observational studies
• Some CQI studies
• Some chart review studies
• The rule of thumb is run everything by the IRB
  first by phone and/or writing before beginning

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A Final Thought

• YOU CANT WIN THE LOTTERY
• IF
• YOU DONT BUY A TICKET!!!

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For more information

• About Tenure, Clinical Scholarship and promotion
  email me
• mpato_at_usc.edu