At Queen's Anesthesiology, research is an integral part of residency training.
Our residency research training plan 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. 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?
Phase 1 - Fundamentals of Research and Critical Appraisal
PGY-1, July 1:
• Residency Program Director (RPD) assigns each resident to 1 Faculty "Scholarship Mentor" who will help the resident meet the RCPSC Specific Objectives for Scholarship (see App. 1).
• resident will attend introductory research course (http://meds.queensu.ca/medicine/obgyn/research/course2004.htm)
• resident will consult Queen's Resident Research resources (http://meds.queensu.ca/medicine/obgyn/links/roadmap.htm)
• resident will also attend Core Anesthesiology Lecture on the critical appraisal of research literature.
• 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 resident uses their idea.
• resident will be required to critically appraise a published research data article relevant to the specialty of Anesthesiology.
PGY-1, October 1:
• resident will submit to RPD a selection of three research study articles, only one of which will be approved (by October 15) by the "Resident Research Committee" (RRC) for the resident to critically appraise
• The resident will evaluate the research study article according to "Journal Club Appraisal Criteria" (see App. 2) in a written essay 1,500 to 3,000 words long.
PGY-1, February 15:
• resident will submit Critical Appraisal Essay to RPD for review by RRC
PGY-1, Resident Research Day:
• Prize will be awarded to resident for writing the "Best Critical Appraisal Essay" which will be published in the Resident Research Day syllabus
Phase 2 - Research Project Conception and Design
PGY-2, July 1:
• resident (with Mentor) to review "research idea bank", speak to investigators of ongoing Departmental studies and think about ideas for their own research project
• resident (with Mentor) will also pursue Research Advisor (if not same as Mentor) for research project.
PGY-2, October 1:
• resident to submit to RPD two one-page preliminary proposal summaries for two possible research projects (with 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 October 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 etc.) but the research question should be relevant to anesthesia, critical care and/or pain management. Prospective studies are preferred over retrospective data reviews or case studies. If a case study or retrospective data review is chosen, the resident will provide sound rationale for selecting this study design (e.g., new area, rare outcome), and the resident will be expected to heavily qualify observed results and clearly describe the limitations in interpreting data from such studies.
• Upon approval of the study to be pursued, the resident will write a full proposal (with the heading format: clinical need, knowledge gap, hypothesis, study design, pitfalls/feasibility/project timeline) which would be 3,500 - 4,500 words long and quite similar to a research grant application.
Residents are directed to several resources on how to write research proposals (see: http://www.cihr-irsc.gc.ca/e/1465.html)
PGY-2, February 1:
• resident (with Advisor's assistance) will submit full research proposal to RPD (for review by the RRC) and present this proposal as an oral communication at Grand Rounds in the month of February
• resident will be expected to incorporate feedback from RRC (and from Departmental comments at rounds) in order to improve their proposal for Resident Research Day
• resident will present research proposal at Resident Research Day. One resident will be awarded prize for best research proposal.
Phase 3 - Conduct of Research/Presentation of results
PGY-2, April 1:
• resident (with Advisor's assistance) will start to carry out research plan, e.g. Ethics submission, data recording instruments, patient recruitment etc.
• In situations where the proposed project turns out to be unfeasible (e.g. Ethics not approved, patient recruitment inadequate, equipment unavailable etc.) an acceptable alternative to completing the proposed project is for the resident to play a substantial role in gathering, analysing and interpreting data from another proposed project and/or an ongoing project. A less preferable alternative would be to conduct a literature review, however, and such a review would have to be based on some sort of analysis of study data from several (>3) published studies.
• If and when an alternative project must be pursued, the resident must submit an explanatory letter to the RPD (for review by RRC) together with a one-page summary of the alternate project or review (with the heading format: clinical need, knowledge gap, hypothesis, study design, pitfalls/feasibility/project timeline).
PGY-3, August 1:
• resident will submit progress report to RPD (for review by RRC) describing steps which have been accomplished thus far as well as any pilot data collected to date. Comments/suggestions to resident from RRC re: study troubleshooting recommendations for improvement will be returned back to the resident by September 1.
PGY-3, January 1:
• resident will submit study data in abstract form to RPD (for review by RRC) and resident will also make an oral research presentation in the month of January.
• resident will be expected to incorporate feedback from RRC (and from Departmental comments at rounds) in order to improve their proposal for Resident Research Day
PGY-3, Jan. 15:
• abstract submission to CAS Meeting resident competition
• project presentation at Resident Research Day; Gold, Silver and Bronze medals for top 3 project presentations
• In cases where logistics do not allow for the study to have been completed in time for PGY-3 Resident Research Day, the resident must write an explanatory letter to the RPD together with a reasonable prediction for the date of study completion. In such cases, the resident would then be expected to present their study at PGY-4 Resident Research Day.
PGY-4, July 1:
• resident submits draft of research manuscript, in a publishable format, to RPD (for review by RRC) comments back to resident by September 1
PGY-4, December 15:
• resident submits acknowledgement of receipt of research manuscript from peer-reviewed journal to RPD. If the manuscript is not appropriate for a peer-reviewed journal, resident would be expected to publish the manuscript in some other venue (e.g. Queen's Anesthesiology Research Newsletter, Queen's Health Sciences Journal, etc.)
• residents are expected to have completed their research by the end of PGY-4 thus leaving the entire PGY-5 year to focus on FRCPC exam preparation.
Objectives of Training and Specialty Training Requirements in Anesthesia Approved by Education Committee, 2000
Specific Objectives (Revised into CanMEDS format - May 2000)
At the completion of training, the resident will have acquired the following competencies and will function effectively as:
- Develop, implement, and monitor a personal continuing education strategy.
- Critically appraise sources of medical information.
- Facilitate learning of patients, students, and other health professionals.
- Contribute to the development of new knowledge.
- Develop criteria for evaluating the anesthetic literature.
- Critically assess the literature using these criteria.
- Describe the principles of good research.
- Using these principles, judge whether a research project is properly designed.
Journal Club Guidelines
Suggested Guidelines for Critical Appraisal of Papers for the Anesthesia Journal Club
By Dr. Joel Parlow (Revised 2002)
1. Title: Does it seem like an important problem?
2. Authors, institution and country of origin?
1. What is the problem being addressed?
2. What is the current state of knowledge of the problem studied?
3. What is the hypothesis being tested?
4. How does testing the hypothesis help solve the stated problem?
1. Study design:
a) Prospective vs. retrospective
b) Observational vs. Experimental
c) Randomized or not
d) Blinded or not
2. Population studies:
a) Human, animal, other
c) Controls: experimental vs. historical
d) Is the sample size/power sufficient
e) Is it similar to your own practice?
3. Is the study ethically sound?
4. Exclusions: what groups are excluded and why?
5. Experimental protocol
a) Is it designed to test the hypothesis?
b) Is it detailed enough to be reproducible
c) Is the methodology validated?
d) Are the drugs/equipment used detailed?
e) How does the randomization take place?
6. What are the primary endpoints?
7. Is the protocol clinically relevant?
8. Data collection and analysis
9. Statistical analysis: Is it appropriate?
1. Are the groups comparable?
2. Were any subjects/data eliminated?
3. Are adequate details of results provided? - data, graphs, tables
1. What is the main conclusion of the study?
2. Do the results support this conclusion?
3. Do the results address the stated purpose/hypothesis of the study?
4. How do the authors explain the results obtained?
5. Are there any alternative interpretations to the data?
6. Are the results clinically as well statistically relevant?
7. How do the results compare with those of previous studies?
8. What do the results add to the existing literature?
9. What are the limitations of the methods or analysis used?
10. What are the unanswered questions for future work?
Applicability of the paper
1. Have you learned something important from reading this paper?
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."
Resident Research Publication Successes
Koumpan Y, Murdoch J, Beyea JA, Kahn M, Colbeck, J. (2016). Establishing a definitive airway in a trauma patient with a King LT in situ in the presence of a closed head injury and difficult airway: "Between the Devil and the Deep Blue Sea." A A Case Rep. 2017 Mar 15;8(6):139-141.
Leitch J, van Vlymen J. Managing the perioperative patient on direct oral anticoagulants. Can J Anaesth. 2017 Jun;64(6):656-672. doi: 10.1007/s12630-017-0868-2. Epub 2017 Apr 20.
Mizubuti GB, Koumpan Y, Hamilton GA, Phelan R, Ho AMH, Tanzola RC, Wang LTS. Retrograde Extrusion of Coronary Thrombus During Urgent Aortocoronary Bypass Surgery: A Case Report. A A Case Rep. 2017 May 15;8(10):268-271.
Mizubuti GB, Wang L, Ho AM, Tanzola RC, Leitch J. Perioperative Management for Abdominal Surgery in Bilateral Diaphragmatic Paralysis: A Case Report and Literature Review. A A Case Rep. 2017 Jul 6.
Murdoch JAC, Koumpan Y, Beyea JA, Khan M, Colbeck J. In Response. A A Case Rep. 2017 Jul 17.
Gilron I, Chaparro LE, Tu D, Holden RR, Milev R, Towheed T, DuMerton-Shore D, Walker S. Combination of pregabalin with duloxetine for fibromyalgia: A randomized controlled trial. Pain. 2016
Ho AM, Mizubuti GB, Dion PW. Proactive Use of Plasma and Platelets in Massive Transfusion in Trauma: The Long Road to Acceptance and a Lesson in Evidence-Based Medicine. Anesth Analg. 2016 Dec;123(6):1618-1622.
Hoffer D, Smith SM, Parlow J, Allard R, Gilron I. Adverse event assessment and reporting in trials of newer treatments for post-operative pain. Acta Anaesthesiologica Scandinavica. 2016 Aug;60(7):842-51
Koumpan Y, Engen D, Tanzola R, & Saha T. (2016). Periarticular morphine-induced Sphincter of Oddi spasm causing severe pain and bradycardia in an awake patient under spinal anesthesia: an important diagnostic consideration. A&A Case Reports, 7(7), 152-154
Koumpan Y, Murdoch J, Beyea JA, Kahn M, Colbeck, J. (2016). Establishing a definitive airway in a trauma patient with a King LT in situ in the presence of a closed head injury and difficult airway: "Between the Devil and the Deep Blue Sea." A&A Case Reports, accepted for publication on September 16, 2016
Murdoch J, Ramsey G, Day AG, McMullen M, Orr E, Phelan R, Jalink D. Intraperitoneal ketorolac for post-cholecystectomy pain: a double-blind randomized-controlled trial. Can J Anaesth. 2016 Jun;63(6):701-8. doi: 10.1007/s12630-016-0611-4. Epub 2016 Feb 10.
Doyle P, VanDenKerkhof E, Edge D, Ginsburg L, Goldstein D. Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey. BMJ Qual Saf 2015;24:135-141 doi:10.1136/bmjqs-2014-003142
Gerlach R, Mark D, Poologaindran A, Tanzola R. Cardiac rupture from blunt chest trauma diagnosed on transesophageal echocardiography. Anesth Analg. 2015
Johnson AP, Mahaffey R, Egan R, Twagirumugabe T, Parlow JL. Perspectives, perceptions and experiences in postoperative pain management in developing countries: A focus group study in Rwanda. Pain Res Manag 2015;20(X):1-6
Mizubuti GB, Allard RV, Tanzola RC, Ho AM. Pro: Focused Cardiac Ultrasound Should be an Integral Component of Anesthesiology Residency Training. J Cardiothorac Vasc Anesth. 2015
Mizubuti GB, Koumpan Y, Hamilton GA, Phelan R, Ho AMH, Tanzola RC & Wang L. (2016). Retrograde extrusion of coronary thrombus during urgent aorto-coronary bypass surgery. A&A Case Reports, accepted
Curtis R, Schweitzer A, van Vlymen J. Reversal of warfarin anticoagulation for urgent surgical procedures. Can J Anaesth. 2015
Zalan J, Wilson R, McMullen M, Ross-White A. Frailty indices as a predictor of postoperative outcomes: a systematic review protocol. JBI Database System Rev Implement Rep. 2015
Florea A, van Vlymen J, Ali S, Day AG, Parlow J. Preoperative beta blocker use associated with cerebral ischemia during carotid endarterectomy. Can J Anaesth. 2014
Hoffer D, Shyam V. Concurrent open reduction and fixation of the femur and humerus under spinal and ultrasound-guided interscalene catheter anaesthesia in a cachectic patient on hemodialysis. International Journal of Perioperative Ultrasound and Applied Technologies. 2014: 3(1): 19-21
Koumpan Y, VanDenKerkhof E, van Vlymen J. An observational cohort study to assess glycosylated hemoglobin screening for elective surgical patients. Can J Anaesth. 2014
Smithson LJ, Krol KM, Kawaja MD. Neuronal degeneration associated with sympathosensory plexuses in the trigeminal ganglia of aged mice that overexpress nerve growth factor. Neurobiol Aging. Neurobiol Aging. 2014 Dec;35(12):2812-21. 2014
Techasuk W, Bernucci F, Cupido T, González A, Correa J, Finlayson R, Tran De Q. Minimum Effective Volume Of Combined Lidocaine-Bupivacaine For Analgesic Subparaneural Popliteal Sciatic Nerve Block. Reg Anesth Pain Med. 2014 Mar-Apr;39(2):108-11.
Techasuk W, González AP, Bernucci F, Cupido T, Finlayson RJ, Tran de Q. A randomized comparison between double injection and targeted intracluster-injection ultrasound-guided supraclavicular brachial plexus block. Anesth Analg. 2014 Jun;118(6):1363-9. doi: 10.1213/ANE.0000000000000224
Wong K, Phelan R, Kalso E, Galvin I, Goldstein D, Raja S, Gilron I. Antidepressant drugs for prevention of acute and chronic postsurgical pain: early evidence and recommended future directions. Anesthesiology. 2014
Ashbury T, Milne B, McVicar J, Holden RR, Phelan R, Sudenis T, VanDenKerkhof EG. A clinical tool to predict adverse behaviour in children at the induction of anesthesia. Can J Anaesth. 2014
Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev. 2013
Gerlach RM, Saha TK, Allard RV, Tanzola RC. Unrecognized tamponade diagnosed pre-induction by focused echocardiography. Can J Anaesth. 2013
Gerlach RM, Tanzola R, Allard R. Echo rounds: intraoperative diagnosis of transient pseudo-severe aortic stenosis. Anesth Analg. 2013
Gilron I, Shum B, Moore RA, Wiffen PJ. Combination pharmacotherapy for the treatment of fibromyalgia (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010585. DOI: 10.1002/14651858.CD010585.
Mahaffey R, Wang L, Hamilton A, Phelan R, Arellano R. A retrospective analysis of blood loss with combined topical and intravenous tranexamic acid after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2013
Shum S, Tanzola R, McMullen M, Hopman WM, Engen D. How well are prebooked surgical step-down units utilized? J Clin Anesth. 2013
Tanzola RC, Walsh S, Hopman WM, Sydor D, Arellano R, Allard RV. Brief report: Focused transthoracic echocardiography training in a cohort of Canadian anesthesiology residents: a pilot study. Can J Anaesth. 2013
Chaparro LE, Lezcano W, Alverez HD, Joaqui W. Analgesic effectiveness of Dipyrone (Metamizol) for postoperative pain after herniorrhaphy: a randomized, doublé blind, dose response study. Pain Pract. 2012; 12(2):142-7.
Chaparro LE, Clarke H, Valdes PA, Mira M, Duque L, Mitsakakis N. Adding pregabalin to a multimodal analgesic regimen does not reduce pain scores following cosmetic surgery: a randomized trial. J Anesth. 2012; 26(6):829-35.
Chaparro LE, Wiffen PJ, Moore RA, Gilron I. Combination pharmacotherapy for the treatment of neuropathic pain in adults. Cochrane Database Syst Rev. 2012;7:CD008943. doi:10.1002/14651858.CD008943.pub2. Review.
Henry R, Cahill CM, Wood G, Hroch J, Wilson R, Cupido T, Vandenkerkhof E. Myofascial pain in patients waitlisted for total knee arthroplasty. Pain Res Manag. 2012 Sep-Oct;17(5):321-7.
Witt A, Iglesias S, Ashbury T, Evaluation of Canadian family practice anesthesia training programs: can the Resident Logbook help? Can J Anaesth. 2012; 59(10):968-73.
Zamora JE, Nolan RL, Sharan S, Day AG. Evaluation of the Bullard, GlideScope, Viewmax, and Macintosh laryngoscopes using a cadaver model to simulate the difficult airway. J Clin Anesth. 2011; 23(1):27-34.
Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland D. Sub-Glottic Secretion Drainage for the Prevention of Ventilator Associated Pneumonia: A Systematic Review and Meta Analysis. Crit Care Med. 2011; 39(8):1985-91.
McKechnie K, Froese A. Ventricular tachycardia after ondansetron administration in a child with undiagnosed long QT syndrome. Can J Anaesth. 2010 May;57(5):453-7. doi: 10.1007/s12630-010-9288-2.
Tanzola RC, Erb J, Endersby R, Milne B. Transesophageal echocardiography images of pulmonary artery compression by benign follicular lymphoid hyperplasia. Can J Anaesth. 2010 Nov;57(11):1042-3. doi: 10.1007/s12630-010-9368-3.