With the New Year here, my wish for the upcoming year is to see better integration between researchers, clinicians, and patients. While there are times that each of these worlds have come together to function as one, many times, they are far apart and working in their own little separate space.
We see research that has little to no clinical value. I am not referring to foundational research that needs to show some proof of concept that needs to happen before clinical research can take the concept and prove it in the clinical setting. I am referring to research that tries to pretend it has clinical relevance that does not have a scientific foundation (see this episode of PT Inquest Episode 141 on Lasers for an example).
Another challenge to the clinical value of research is within the balance of internal and external validity of a study. A study with strong internal validity is one that is well controlled with all variables and confounders accounted for. The problem with this study from a clinical perspective, is when is the last time in the clinic you could control all the variables with your patients and clinic environment? You cannot control for everything in the real world, as it is too complex and patients are unique individuals.
Therefore, clinicians look at these studies and say, “That’s cool, but it would never work in my clinic or my patients don’t look exactly like that so it doesn’t apply”.
However, researchers rave over these studies because they are so well controlled and better conclusions can be made. Contrast that with a study that has more external validity, aka it looks like real clinical life. Clinicians look at these studies and get excited because the study actually looks like what they are doing in the clinic every day. Unfortunately, some pure researchers balk at these studies because of the poor controls put into place, so trying to draw conclusions from the results are sketchy. What we are left with is research that clinicians say is worthless for their clinical practice, that researchers think are amazing pieces of research. Alternatively, a study that is trashed by the reviewers of the journal and other researchers as being poor research because things were not controlled for properly. I hope that researchers can appreciate clinical research, that while we have to be careful with conclusions drawn from them they are important for clinical translation. Similarly, clinicians can look at both a clinical study with more external validity and realize they also need to be careful with conclusions drawn from it and realize that these studies are best used when balance with the more structured internally valid study with all sorts of controls. We need both types to come to the best conclusions and use for clinic.
While all of this fighting is going on between clinician and researcher regarding the research, the patient is sitting on the outside going, “hey, what about me?”
I really like the statement from patient advocate groups – “no more research on or about us without us”.
From a clinical translational standpoint, we may have sometimes lost focus on the purpose of the research. This research is not for the researcher to get tenure or for the clinician to boast about their ability to use evidence-based practice and justify payment for their services, ultimately it should be to help patients get better. Similar to how we should include the patient and use a shared decision making process in the clinic to maximize the patient outcome, we also need to look at utilizing this similar approach as we develop our research studies. This can be done by the researcher utilizing oversight from a patient advocate to make sure the research involves the patient and ultimately can help the patient the most. It can also involve the clinician sharing the evidence from the research with the patient to help in the shared decision making model of care.
To become more fully integrated researchers need to listen to clinicians and set up research that meets the external validity demands of a chaotic clinical environment, along with running other studies that fulfill the well-controlled internal validity demands of scientific rigor. It is through the integration of both of these study methods that we can come to better conclusions on caring for patients. This all needs to be done with the patient if the research ultimately is on and/or about the patient. For all of this to work clinicians and patients have to offer their input and ideas but also themselves. Researchers need clinical sites, so clinicians need to become involved in data collection. Patients have to become participants in the studies. This is my New Year wish that we can all (researcher, clinician, and patient) integrate together to help each other provide better evidence, better patient care, and better outcomes.