At Queen's Anesthesiology, research is an integral part of residency training.
Our residency research training plan (please see "Research Traning Plan" below) is based upon the following rationale:
Is research a necessary part of anesthesia training?
The principles and practice of anesthesiology are founded upon physiology and pharmacology which have their roots in basic research, and more recently, epidemiological research. Recent revolutions in patient care are results of pioneering research (e.g. muscle relaxants, "quick-offset" anesthetics, regional anesthesia, pulse oximetry). Patient care is facilitated by practice guidelines & consensus recommendations (e.g. advanced cardiac life support (ACLS), difficult airway algorithm) which are based largely on clinical research. Recent major advances in investigative techniques, research funding and global research productivity have provided tremendous opportunities for anesthesia research in Canada. Clinical medicine is not practiced in a vacuum but rather in an ever-changing environment of research and innovation. Anesthesiology training must incorporate research in order for our specialty to advance among the forefronts of medicine.
How can anesthesia residents receive research training?
Role models and mentorship are crucial to residency research training and thus requires department-wide faculty involvement. Anesthesiology residents come from diverse backgrounds and identify with faculty with diverse strengths (e.g. clinical, teaching, research, administration). If ALL faculty emphasize the importance of research, it is much more likely that this message will come across to residents.
Firstly, one needs a structured introduction to the fundamentals of biomedical research (e.g. research methods course) followed by the development and execution of a research project(s). Clinical training is demanding and time consuming; therefore a practical plan and timetable for research project completion is critical. Communication of ideas is vital for research, thus emphasizing the importance of: a) "resident research day" - a forum for oral presentation of research proposals & results and b) publishing new knowledge in peer-reviewed journals (widespread knowledge translation).
Classical areas of research:
Biomedical research is traditionally hypothesis-driven in that it uses methods which test a specific hypothesis or question e.g. Does preload affect contractility? This type of approach has been used in several areas:
• describes previously unknown biological phenomena
e.g. Do excitatory amino acids transmit pain?
• prospective, randomized, double-blind clinical trials
e.g. Do beta-blockers decrease perioperative mortality?
• epidemiological studies (study the distribution and determinants of disease in a population)
e.g. Is postoperative nausea and vomiting more common in women than men?
Methods which use a random sample of subjects and are prospective, randomized, double-blind and controlled are least subject to bias and more likely to lead to a generalizable conclusion. Data from non-randomized studies, retrospective chart reviews and case series may generate new hypotheses but have serious limitations which could result in misleading conclusions.
Can clinically motivated questions be answered using research methods?
Routine clinical practice often gives rise to scores of "research questions" (i.e. unmet knowledge gaps) throughout one day in the operating room. Armed with curiosity, creativity and a thorough understanding of research principles many important questions can be, and have been, answered by carefully executing a research project plan (please see "Research Project Plan" below). Some examples include:
Efficacy of treatment interventions, teaching, resource management:
• do preclinical teaching sessions improve intubation successes by medical students?
• what clinical features predict the likelihood of a failed spinal?
• what dose/duration of beta-blockade decreases perioperative cardiovascular risk?
• do intraoperative opioids cause postoperative hyperalgesia?
• does preoperative cardiac screening prevent perioperative morbidity and mortality?
• does a preoperative assessment clinic improve operating room efficiency?
What clinical features predict the likelihood of:
• difficult intubation?
• epidural hematoma?
• postoperative respiratory failure?
• failed weaning from cardiopulmonary bypass?
• intraoperative awareness?
Resident Research Training Plan
*Phase 1: Research Introduction – Project Conception and Design*
- Residents to attend “Introduction to Research” lecture as part of Transition to Discipline seminar series.
- Residents given time/location of Queen’s PGME Introduction to Resident Research Day (usually in November)
- Resident will be told about the “research idea bank” which accepts "idea deposits" (with the heading format: clinical need, knowledge gap, hypothesis, study design, pitfalls/feasibility/project timeline) from contributors who will be later credited if the resident uses their idea.
PGY-1, November 15:
- Residents to submit 2-3 briefly described ideas for a resident research project to the “Resident Research Committee” (RRC). Descriptions will briefly address the heading format: clinical need, knowledge gap, hypothesis, study design, pitfalls/feasibility/project timeline.
These proposals will be reviewed by the RRC and only one will be approved (by December 15) for the resident to write a full proposal on.
- For the proposed project, the research area is flexible (could be laboratory, clinical, survey, epidemiological, systematic review, QA/QI project etc.) but the research question should be relevant to anesthesia, perioperative medicine, critical care and/or pain management. Projects should include a “knowledge mobilization” plan involving a commitment to publish the project. (Note: current, related publications can and should be used as a template to guide planned projects.)
- While the project is being planned, the resident will seek out at least one research supervisor (at least one must be a faculty member of Queen’s Anesthesiology & Perioperative Medicine).
- The resident and research supervisor will seek out collaborators and funding sources necessary for the project.
- Upon approval of the study to be pursued, the resident – together with the research supervisor – will write a full proposal (with the heading format: clinical need, knowledge gap, hypothesis, study design, pitfalls/feasibility/project timeline) which should be of sufficient detail to guide the conduct of the project. Residents are directed to several resources on how to write research proposals (e.g. see: https://www.queensu.ca/vpr/resources/proposal-writing).
PGY-1, February 15:
- The resident (with supervisor) will submit the full research proposal to the RRC and present this proposal as an oral communication at Grand Rounds in February/March.
- The resident will be expected to incorporate feedback from RRC (and from Departmental comments at rounds) in order to improve their proposal presentation for Resident Research Day.
- The resident will present research proposal at Resident Research Day.
- The resident (with supervisor and collaborators) will start to carry out research plan, e.g. Ethics submission, data recording instruments, participant recruitment etc.
- In situations where the proposed project turns out to be unfeasible (e.g. Ethics not approved, participant recruitment inadequate, equipment unavailable etc.), the resident will pursue an alternative research project.
PGY-2 to PGY-5:
- The resident will present annual research updates at Anesthesiology Research day each year and provide quarterly updates to the PD to discuss any barriers to completing the project.
Suggested guidelines for developing a research project plan
As an example, the following research plan might have been used in the past to develop a research project on features predictive of difficult intubation:
e.g. "Does degree of mouth opening predict ease of intubation?"
Related area of clinical "need":
e.g. "Difficult intubation is a potentially fatal anesthetic complication. The ability to predict difficult intubation may allow for proper preparation and decreased risk of adverse outcomes."
Current knowledge gaps in this area:
e.g. "At the time of writing, very little has been published about anatomical features predictive of difficult intubation..."
Hypothesis to be tested:
e.g. "Based on preclinical anatomy studies, this project seeks to test the hypothesis that decreased mouth opening is predictive of difficult intubation."
Proposed study design:
e.g. "We propose to prospectively evaluate 500 surgical patients. Prior to surgery, degree of mouth opening will be quantified. During laryngoscopy/intubation difficulty of intubation will be graded using a clinical scoring tool."
Possible pitfalls, feasibility and expected project timeline:
e.g. "Our methods for quantifying mouth opening and scoring difficulty of intubation first need to be validated. It may be difficult to recruit 500 patients and complete the project during the span of one resident's training therefore, this will be a collaborative multicenter study. It is unclear whether 500 patients will provide the necessary statistical power to test this hypothesis. Based on an interim analysis after 250 patients, a subsequent sample size calculation will be performed and, if necessary, the number of study patients will be increased above 500."
Queen's University Anesthesiology Research Day is an annual event that consists of biomedical research presentations by trainees (residents, students and fellows) affiliated with the Queen's Department of Anesthesiology & Perioperative Medicine. Presentations are judged by a visiting professor and two Queen's Faculty. Prizes are awareded for excellence of trainee presentations and the visiting professor delivers a keynote address. Typically held in the spring of each year, Research Day highlights the conslusion to our academic year.