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Research and audit

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Tell me about your research experience.

Tell them about the research experience you have, covering the following areas:

  • Type of research you have done and your involvement in it. Whether you were responsible for ethics committee approval and R and D approval. Who initiated the idea and who wrote the protocol, patient information leaflet etc? Whether you were the principle investigator
  • Tell them briefly about the research - type of research (RCT, multicentre study etc), methods and the outcomes. Tell them if you have published it and that you are the first author (if you are!)
  • Explain what you gained out of research

Is a higher degree important in modern medicine, and gastroenterology in particular?

Do you think all SpRs should do research?

The government has made a strong commitment to research. Research is (thus) one of the key components of clinical governance. However, it does not mean that all doctors should be involved in research. Research is expensive. Research for the sake of CV will only lead to waste of resources, which can be more appropriately utilised involving people interested in research.

 

You can always involve yourself in research without undertaking a higher degree. You can always support research by helping to recruit patients to clinical trials from your practice.

 

However, it is important for all physicians to understand the principles of research, as it underpins evidence-based medicine. So, for example, it is important to be able critically to appraise a paper/research paper and form a judgement as to whether the conclusions presented can be implemented in your own practice. These skills are best acquired through exposure to a degree of research but can be gained through journal clubs too or attending appropriate courses.

Tell me about your research. Assume that you are talking to a group of charity workers from your funding organisation.

Essentially, tell them about your research in lay terms - the aims, the methods and how it may benefit the intended group. Try to relate it to the aims of the charity (if provided)

 

How much of your research is of your own design and how much was guided by your supervisor?

How did you organise your research project? Did your supervisor write your grant application?

Be honest. Tell them about the extent of your involvement in the research project. You may just have collected the data or consented the patients for recruitment. Whatever may have been your involvement, it is still a plus point that you were involved in a research project.


I am worried about your lack of research experience.

Tell them, you do understand the importance of research. Quote whatever research experience you have (even if minimal). Tell them you are interested in clinical work and thus may not have produced the best research.

Go on to say that you do understand the principles behind research and research governance and have acquired valuable research skills, like critically appraising a research paper by attending training sessions and journal clubs.

 

Why is research important?

Research is important for the advancement of medical sciences.


When would you say a piece of research is good research?

Clearly, not all research is well conducted. The quality of the research depends on:

  • Hierarchy of study design - in the following order RCT, non-randomised controlled trial, observational studies, case reports, expert opinion
  • Study quality - assessing the study for randomisation process, blinding of the subject/investigator, use of appropriate statistics, whether the study was adequately powered, whether the study and control groups were well matched, whether all the study subjects were accounted for in the results, etc
  • Generalisability - whether you can implement the conclusions of your study to your practice (this will depend on whether the study group is in any way similar to your practice patients)

If you are asked to read one section in an article, which section will you read? Why?

Methods section is the most important to me because unless appropriate methods are used to answer the relevant research question, the results and conclusions may be flawed. Of particular importance in methods are:

  • Process of randomisation
  • Whether the investigator and subjects were blinded
  • Process of recruitment
  • Whether ethics and R and D approval were sought
  • Power of the study
  • Statistics used and its appropriateness
  • Baseline characteristics of the study and control group, and whether they are adequately matched

How will you statistically correct for the unaccounted people in a clinical trial?

By using intention-to-treat statistics
Basically, by using this statistic you include all the patients recruited (disregarding any drop-outs) in calculating the results.

How do you go about setting up a research project?

Steps:

  • Asking the right research question. Decide what specific area you wish to research. Once you have decided on a topic, do a literature review of the topic, focusing on research in the last 2-3 years
  • Finding a person/expert interested in the research question. Alternatively, you may wish to talk to a unit/person with an established research track record and check whether they have any interesting projects for you
  • Arranging funding
  • Further steps, like ethics and R and D approval
  • (You can read more at) http://www.tig.org.uk/research_intro.htm

When doing research, what is the one most important factor to get right?

Planning:
What you want to research and where. A good project (i.e. a project that is practical, feasible and answers an important question) needs thorough planning. A pilot run is also important to ensure that everything is working according to plan.

 

Would you like to participate in research if you were appointed?

 

  • You could say that your prior research experience has kindled a strong interest and you wish to build on your experience by getting involved in further projects
  • Alternatively, you could say that you do not see yourself as principal or chief investigator but you understand the role of research and will help in consenting and recruiting patients for research.

Should all research be carried in tertiary centers or do DGHs have a role?

The majority of doctors work in DGHs and the majority of patients are treated in DGHs. So DGHs are vital in any research conducted within the NHS. Besides, research is a vital part of the clinical governance framework and, as such, involves all NHS hospitals.

 

What are the current research developments in your field of interest?

Mention one or two research developments.

What is evidence-based medicine (EBM)?

EBM essentially means application of the best evidence from the best medical research to treat patients.
David Sackett et al. define EBM as "integration of best research evidence with clinical expertise and patient values"
(example of EBM - use of thrombolytic therapy in ST elevation MI).

What are the pros and cons of evidence-based practice?
Pros:

EBM is essential for the application of best research evidence for the benefit of the patients.

Cons:

  • Publication bias - Negative studies may not always be published, as journals tend to publish new and positive studies.
  • ‘Cookbook’ medicine - Guidelines and recommendations may be too prescriptive and thus suppress clinical freedom.
  • It is impossible to practise EBM with every clinical decision, as there may be no good evidence to support clinical judgement.

What is your understanding of the term "research governance”?

Research governance is about the ethos of best practice and ethical methods when researching. Research governance is about ensuring the highest standards of quality in clinical research. This covers scientific quality and standards of ethics, and all related management aspects in the setting up, conduct, reporting and progression to healthcare improvements. It makes certain that the interests of research participants come first. The DoH has published The Research Governance Framework 2005. This includes, for example:

  • Ethics and R&D approval is a must before any research begins
  • Researchers bear day-to-day responsibility for the conduct of research adhering to the principles of good practice
  • Appropriate management of financial and other resources by the researchers

Research governance is needed to:

  • Safeguard participants in research
  • Protect researchers/investigators (by providing a clear framework to work within)
  • Enhance ethical and scientific quality
  • Minimise risk
  • Monitor practice and performance
  • Promote good practice and ensure that lessons are learned

What are the different levels of evidence available?

Grading of evidence:

 

  • Ia: Systematic review or meta-analysis of randomised controlled trials
  • Ib: At least one randomised controlled trial
  • IIa: At least one well-designed controlled study without randomisation
  • IIb: At least one well-designed quasi-experimental study, such as a cohort study
  • III: Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case–control studies and case series
  • IV: Expert committee reports, opinions and/or clinical experience of respected authorities

Grading of recommendations:

  • A: Based on hierarchy I evidence
  • B: Based on hierarchy II evidence or extrapolated from hierarchy I evidence
  • C: Based on hierarchy III evidence or extrapolated from hierarchy I or II evidence
  • D: Based directly on hierarchy IV evidence or extrapolated from hierarchy I, II or III evidence

Do you think evidence-based medicine is applicable to all specialities?

Yes (read the pros and cons above).


What is a systematic review?

A systematic review is a literature review focused on a single question that tries to identify, appraise, select and synthesise all high-quality research evidence relevant to that question. It underpins EBM. The advantages of systematic review are:

  • Large amounts of information can be assimilated quickly by healthcare providers, researchers and policy makers
  • Conclusions are more reliable and accurate because of methods used
  • Results of different studies can be formally compared to establish generalisability of findings and consistency (lack of heterogeneity) of results

Quantitative systematic reviews (meta-analyses) increase the precision of the overall result

(Ref: BMJ 1997; 315: 672-5)

 

What is a meta analysis?

A meta-analysis is a mathematical synthesis of the results of two or more primary studies that addressed the same hypothesis in the same way. It can increase the precision of a result. Meta-analysis is essentially a quantitative systematic review.
(Ref: BMJ 1997; 315: 672-5)

 

What is an audit?

Audit is a vital component of clinical governance.  Clinical audit is principally the measurement of practice against agreed standards and implementing change to ensure that all patients receive care to the same standard.  Audits help to identify and promote good practice and can lead to improvement in service delivery and patient outcomes. It also helps to ensure efficiency by ensuring better use of resources.

 

Tell me about your audit experience.

Discuss your audits (what audit did you do, why you did that particular audit, what deficiencies did the audit reveal, what change was implemented, did you complete the audit cycle etc)

What is the difference between audit and research?

Audit

Research

Aims to review current practice against best practice and to implement change to improve current practice 

Asks the questions: “Are we following best practice?” and “What is happening to patients as a result?”

Aims to derive new knowledge which is potentially generalisable or transferable

 

Asks the question: "What is best practice?" (so aims to establish best practice)

Will never involve a completely new treatment or practice

May involve a completely new treatment or practice

Addresses clearly defined audit questions using a robust methodology, usually asking whether a specific standard has been met. Results are specific and local

Addresses clearly defined questions / hypotheses using systematic and rigorous processes. Designed so that it can be replicated and results can be generalised to other groups

Never involves allocating patients randomly to different treatment groups

May involve allocating patients randomly to different treatment groups

Generates evidence to demonstrate level of compliance with agreed standards. This may lead to changes in practice

Generates evidence to refute, support or develop a hypothesis. May lead to development of new services or practices

A re-audit should be undertaken to demonstrate whether the changes made as a result of the first audit have resulted in an improvement

Will often be a one-off study

(Ref: http://www.ekclinicalauditservice.nhs.uk/)

 

Tell me about the audit cycle.

As clinical audit is not a one-off exercise, it is a continuous cycle of quality improvement.

Audit cycle or spiral

The process of setting standards, systematically evaluating the care of service with respect to the standards, changing practice to improve the care or service and then re-evaluating the resultant care or service. In some cases, the standard will have changed between the audit and re audit. Hence, an audit cycle is sometimes referred to as audit spiral.

What problems are there with the way that SHO audit projects are carried out?

 

  • Very often not done properly (inappropriate audit methods): audit questions are not clearly defined, methods are not robust
  • Not completed
  • Audit cycle not completed
  • Audits not presented
  • Audits done for the sake of CV - hence do not lead to change or improved services

AnaesthesiaUK would like to thank consultantmedicalinterview.com for allowing us to reproduce their material.

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