Transcript Slide 1

Traversing
An
Obstacle Course
To
Research Success:
A Scientific Autobiography
By
Kevin M. Means, M.D.
Undergraduate Education
• Biology major
• Exposed to some research with small
projects working in labs
– Scraped crispy brain from rat skulls
– Cricket study
• Summer job at IBM
• Research not a strong interest yet
Medical School
• Late 1970s
• Howard University College of Medicine
• Education was focused on clinical
medicine - not about research
• Virtually no exposure to research and little
time to pursue it if I wanted to
• Summer job at NIH
PM&R Residency
Rehabilitation Institute of Chicago
• Early 1980s
• Clinically focused training Clinician role
models, mentors
• No real exposure to research
• Observations led to questions concerning
patients and their treatment
– Why do some patients respond to treatment
and others don’t?
– What conditions favor a positive treatment
response?
– What can we do to allow more patients to
improve or benefit?
PM&R Residency
Rehabilitation Institute of Chicago
• Thought about the possibility of asking &
answering questions and scientifically
applying what we learn and changing what
we do.
• These thoughts were transient because
there was no required practical exposure
• RRC now mandates a research
environment
• Our residency program requires residents
to participate in research, writing
University of Arkansas
for Medical Sciences (UAMS)
• Clinical practice (VA) leads to more
questions about improving care
• One question intrigued me:
What can be done for elderly patients who
fall down?
– PCPs not sure what to do → consult PM&R
– Limited personal experience with this
– Sparse literature
• Mostly epidemiologic data & some on etiology
• Limited assessment methods; Nothing on
intervention or outcomes
– Unclear what to do
Intriguing Question Stuck With Me
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Challenging
Needed a solution (practical)
PM&R Literature virtually absent in that area
Found related information (e.g., gait/balance
in stroke) but nothing specifically addressing
falls in elderly patients
• PM&R well suited to address this problem
– because of neurological and musculoskeletal
impairment issues
• Few in our field interested in that area
Uncharted Territory
• I realized I was in “uncharted territory”
• I began to think maybe this was something
I could help answer
• My incentives:
– I could help my patients and
– I could alleviate the frustration I felt in not
knowing how to help them
– Other incentives
What Tools Do I Need?
• I wanted to learn more about this area
• I had some of the clinical tools
• I didn’t have tools as a researcher,
scientific investigator
• I was in a Department with no researchers
– 3 senior/4 junior physiatrists; none were
researchers including the Chair (not atypical
for PM&R Departments)
Obstacles to Research
My Department was not research friendly
• Start-up costs (time and money)
• No research culture; research not valued
– Chair, colleagues, residents
• Poor understanding of researcher needs
– Chair, colleagues
• No critical mass of investigators
• No protected time
The Endocrinologist
• I sought help elsewhere on my campus;
eventually, I found - Robert W. Harrison
– A successful, established & funded investigator,
also a busy clinician and administrator
• Bob became my first research mentor
• We discussed my clinical problem/area of
interest, absent research knowledge,
willingness to learn
• Bob knew nothing about PM&R, and I knew
nothing about endocrinology
The Endocrinologist (continued)
• Bob taught me how to think about problems from
a research perspective; Goal: develop an
application for grant support to study the problem
• Our research areas were so different - he couldn’t
hand me a grant and say, “Here, do it like this”
• I had to learn research process “language”
Clinical Problem  formulated into  answerable
research question  incorporated into  grant
proposal with supporting information
• Research team building, where & how to apply,
etc.
My First Research Grant
• Eventually, I was able to go through this
process and submitted a proposal for a
UAMS medical foundation (intramural)
grant
• It proposed a researchable question
• After revision & re-submission it was
accepted
• I got started -1990
My First Research Grant
Forest vs. Trees
• To prevent falls (forest) you need to
improve balance (tree)
• Balance must be measured (tree) to
assess improvement
• At the time, few reliable ways of
measuring balance
• Our funding was for developing and
testing a device to measure balance (tree)
Research Team
• Team vs. Individual sports
• Winning teams and role players
• During the process of my first grant
application, I found two collaborators –
– Dan Rodell, Ph.D., LCSW
– James Smith, Ph.D.
Research Team
• Dan the PhD Social Worker
– Had some experience with the research
process; worked in the VA
– Knew nothing about PM&R
– Interested in research but had few
opportunities
• Dan became interested in this as a
research project
• Dan became a named collaborator on the
UAMS foundation grant
Research Team
• Jim the Engineer
• We needed a machine that people could stand
on to measure baseline balance; validated by
people with known good and bad balance
• Jim would build the balance machine
• Dan and I knew nothing about the engineering
part of the project
• Jim had a family tragedy and was not able to
build the machine; we were months behind
schedule
• Eventually, the machine was built; we had to
improvise
My Second Grant
• Next goal: Use the balance machine for a
small pilot study; apply for more grant
money to buy a commercially available
machine
• That pilot study involved an exercise
intervention and the balance machine was
used to measure post-intervention
improvement
Formal Training
• As I got more involved in the research process, I
realized how much I still needed to learn if I was
going to do major research
• Knowledge about research design and statistical
analysis was especially lacking
• Some design help was available
• Statistics—Not many statisticians on my campus
– Some statisticians could not converse in plain English
(covariates, survival analysis, ANOVAs, dependent
variables, confounding, independent variables, etc.); I
was ignorant of the terms, and they could not bring it
down to my level.
• Then, an opportunity presented itself….
Formal Training
• On-the-job, Off-campus (OJOC) Program in
Research Design, Clinical Research
Design & Statistical Analysis, U of Michigan
• An 18-month commuter program
– Weekend classes (Fri-Sun) monthly
– Intense coursework with tons of homework
• I took vacation time to go there, and paid
my own travel expenses
A Big Decision
• I was submitting grant applications while
attending the OJOC Program; 12 months
into the Program, a grant I submitted to
NIH got funded for $180K with very good
scores
• I had 6 months to go with the OJOC
Program to earn a Master’s
– It would be tough to launch the NIH study and
complete the program
• LEARN research or DO research?
New Mentor – Jerome Tobis, M.D
• For the NIH FIRST award, I needed a PM&R
mentor
• I met Dr. Jerry Tobis, an emeritus professor and
physiatrist who is a researcher who had done
some work on balance and falls
• He eventually agreed to be my mentor
– Very encouraging; helped me get started
– Delighted to meet a junior colleague with similar
interests
– An expert who could critique the content of my work
PM&R Research in NIH
• In 1992, few physiatrists were funded
by NIH as a principal investigator
– PM&R had researchers, but NIH was
not our primary funding source
– No PM&R institute in NIH (PM&R
research is part of NICHD)
– No PM&R study section in 1992
Gaining Momentum
Once I answered a question, it led me
to more questions and more projects
and more grant applications for
funding
The Missing Piece
• I still needed a statistician to help us write
up collected data
– Dan didn’t know stats very well and Bob
Harrison had left UAMS
• Statisticians I knew were not that helpful
• I eventually met Patricia O’Sullivan, Ed.D.,
who worked for the UAMS College of
Nursing
• Pat and I became long-term collaborators,
along with Dan Rodell
Know Your Competition
• In 1990, I was aware of only 2 or 3 physiatrists
who were doing work similar to mine
• My main “competitors” were geriatricians & PTs
and many of them approached falls prevention
differently
• A race to find the best balance test for people
who fall; then the best predictor of future falls
• Then a race to develop the best intervention; the
best outcomes; then side issues related to falls
• Now a race to target the intervention the most
efficient and cost-effective way
Know Your Competition
Knowing and monitoring “the competition”
helped me to:
– Reinforce my own approach
– Avoid “reinventing the wheel”
– Learn from the discoveries but avoid the
pitfalls of other approaches
I monitored competitors by attending
meetings, asking/answering questions,
peer review (manuscripts & grants), and
correspondence
Example: Obstacle Course
• No “gold standard” test for balance and
mobility in 1990
• We developed, validated, and applied our
own balance & mobility performance test
– the Functional Obstacle Course
• Development of a new test or instrument can
be very tedious and time-consuming
– I used multiple sub-tests
– Quantitative & qualitative scoring system
Why I Do Research?
Research won’t make you rich….But:
• Very rewarding
• Very challenging
• Fun!
– especially when it is shared
• small projects with students/residents
• presenting results to others who are
interested
Why I Do Research?
Can also share findings with patients
Example: When recommending therapeutic
exercise to prevent falls, I can say:
– Research has shown this to be successful
– I have conducted some of this research
myself
– I am recommending something that I have
seen work
– Most patients will work with the same
therapists; same protocols
– Easier to sell patients on this based on direct
experience
Are You A Researcher Type?
• Most physicians are consumers of
research
– Do or prescribe something that others have
found effective
• Researchers are reality testers and need a
questioning mind—I wonder how? If?
Why?
• Researchers are quality improvers and
strive to make things better
Research and Clinical Practice
Complement Each Other
I believe that I am a better clinician because of:
• First-hand experience with improvement of care
through conducting research
• Better observation skills from doing research
I believe that I am a better researcher because of:
• My work as a clinician
• Seeing patients every week who have real
problems
• My patients provide new questions to research
Researchers Need Time To Think
• Critical for a researcher to have time for
thinking
– To “put your feet up on your desk”
• Ideas come to different people in different
ways
• Part of research involves structuring your
schedule so you have thinking time
Use Your Time Wisely
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Find a mentor
Figure out what you need
Design what you need
Critically evaluate what you develop
Read the published literature to see what
others have done so you don’t duplicate what
they did (don’t repeat their mistakes) but you
can improve on what has been done
• Network
The Bottom Line
The focus of my work is to improve my
patients’ quality of life
You Can Never Know It All
The answer to one question leads to more
questions