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Traversing

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Education was focused on clinical medicine - not about research ... Eventually, the machine was built; we had to improvise. My Second Grant ... – PowerPoint PPT presentation

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Title: Traversing


1
Traversing An Obstacle Course To Research
Success A Scientific Autobiography By Kevin M.
Means, M.D.
2
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

3
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

4
PMR ResidencyRehabilitation 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 dont?
  • What conditions favor a positive treatment
    response?
  • What can we do to allow more patients to improve
    or benefit?

5
PMR ResidencyRehabilitation 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

6
University of Arkansasfor 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 PMR
  • 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

7
Intriguing Question Stuck With Me
  • Challenging
  • Needed a solution (practical)
  • PMR Literature virtually absent in that area
  • Found related information (e.g., gait/balance in
    stroke) but nothing specifically addressing falls
    in elderly patients
  • PMR well suited to address this problem
  • because of neurological and musculoskeletal
    impairment issues
  • Few in our field interested in that area

8
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

9
What Tools Do I Need?
  • I wanted to learn more about this area
  • I had some of the clinical tools
  • I didnt 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
    PMR Departments)

10
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

11
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 PMR, and I knew nothing
    about endocrinology

12
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
    couldnt 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.

13
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

14
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)

15
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.

16
Research Team
  • Dan the PhD Social Worker
  • Had some experience with the research process
    worked in the VA
  • Knew nothing about PMR
  • 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

17
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

18
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

19
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
  • StatisticsNot 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.

20
Formal Training
  • On-the-job, Off-campus (OJOC) Program inResearch
    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

21
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 Masters
  • It would be tough to launch the NIH study and
    complete the program
  • LEARN research or DO research?

22
New Mentor Jerome Tobis, M.D
  • For the NIH FIRST award, I needed a PMR 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

23
PMR Research in NIH
  • In 1992, few physiatrists were funded by NIH as a
    principal investigator
  • PMR had researchers, but NIH was not our primary
    funding source
  • No PMR institute in NIH (PMR research is part
    of NICHD)
  • No PMR study section in 1992

24
Gaining Momentum
  • Once I answered a question, it led me to more
    questions and more projects and more grant
    applications for funding

25
The Missing Piece
  • I still needed a statistician to help us write up
    collected data
  • Dan didnt know stats very well and Bob Harrison
    had left UAMS
  • Statisticians I knew were not that helpful
  • I eventually met Patricia OSullivan, Ed.D., who
    worked for the UAMS College of Nursing
  • Pat and I became long-term collaborators, along
    with Dan Rodell

26
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

27
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

28
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

29
Why I Do Research?
  • Research wont 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

30
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

31
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 mindI wonder how? If? Why?
  • Researchers are quality improvers and strive to
    make things better

32
Research and Clinical PracticeComplement 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

33
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

34
Use Your Time Wisely
  • 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 dont duplicate what they did
    (dont repeat their mistakes) but you can improve
    on what has been done
  • Network

35
The Bottom Line
  • The focus of my work is to improve my patients
    quality of life

36
You Can Never Know It All
  • The answer to one question leads to more
    questions
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