RESEARCH AN ESSENTIAL PART OF THE TRAINING OF A WELL ROUNDED SURGEON Prof Franklin Rosenfeldt

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RESEARCHAN ESSENTIAL PART OF THE TRAINING OF A
WELL ROUNDED SURGEONProf Franklin Rosenfeldt
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CARDIAC SURGICAL RESEARCH UNIT
ALFRED HOSPITAL
BAKER HEART RESEARCH INSTITUTE
MONASH UNIVERSITY DEPARTMENT OF SURGERY
MELBOURNE
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NORMAN SHUMWAY

• Shumway commenced at Stanford University in 1958
• where, in collaboration with Dr Richard Lower, he
  undertook ground-breaking work in cardiac
  transplantation.
• He discovered a simplified donor to recipient
  atrial anastomoses and the method of preserving
  the donor heart in ice-cold saline
• In 1967, Dr Christian Barnard, who had observed
  Shumways experimental techniques first hand at
  Stanford performed the first human cardiac
  transplant.
• In January 1968, Shumway performed the first
  cardiac
• transplant in the United States.
• Norman Shumway will always be remembered as the
• true father of cardiac transplantation and for
  training a
• generation of cardiac surgeons.

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NORMAN SHUMWAY
Shumway, his team and his trainees had a major
commitment to research
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Green Lane Hospital Auckland New Zealand
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Major achievements

• Performed the worlds first human tissue aortic
  valve replacement performed in 1962 (independent
  of and almost simultaneous with Sir Donald Ross
  in London).
• Contributed actively to tissue valve research
  almost until his death.
• His passion was paediatric cardiac surgery and
  his work,
• starting in 1969 with the use of deep hypothermic
  circulatory arrest in young infants, led to
  techniques which were quickly adopted worldwide.

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BARRATT BOYES
Barrat- Boyes , his team and his trainees had a
major commitment to research
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Benefits of Research

• Learn Problem Solving Using the Scientific Method
• Learn to Critically Evaluate the literature
• Cultivate an enquiring mind
• Develop an adventurous Spirit eg Shumway and
  Barratt-Boyes
• Understand Language of Science
• Learn Scientific writing
• Learn statistics
• Enhance career opportunities

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Benefits of Research

• Learn Problem Solving Using the
• Scientific Method

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Scientific Method

• Hypothesis

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Scientific Method

• Hypothesis
• Perform an experiment

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Scientific Method

• Hypothesis
• Perform an experiment
• Collect results

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Scientific Method

• Hypothesis
• Perform an experiment
• Collect results
• Accept hypothesis

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Scientific Method

• Hypothesis
• Perform an experiment
• Collect results
• Reject hypothesis

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Scientific Method

• Hypothesis
• Perform an experiment
• Collect results
• reject the hypothesis
• Make another hypothesis

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State the problem to be solved or idea to be
tested The rate of wound infection in the
Alfred has increased

• Hypothesis Staff wearing their theatre clothes
  in the wards or the street bring bugs into the
  theatre
• Perform an experiment Fine everyone who wears
  their theatre clothes outside the theatre 100
  per offence
• Collect results Measure wound infection over the
  next 6 months
• RESULT 1 wound infection rate falls by 50
• Accept the hypothesis

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State the problem to be solved or idea to be
tested The rate of wound infection in the
Alfred has increased

• Hypothesis Staff wearing their theatre clothes
  in the wards or the street bring bugs into the
  theatre
• Perform an experiment Fine everyone who wears
  their theatre clothes outside the theatre 100
  per offence
• Collect results Measure wound infection over the
  next 6 months
• Result 2 wound infection unchanged
• Reject the hypothesis
• Make another hypothesis

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COMPLEXITY IN BIOLOGICAL SYSTEMS AND ITS
IMPLICATIONS FOR CARDIOVASCULAR MEDICINE

• Joseph Loscalzo
• Harvard, Bigham, Editor of Circulation

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RESEARCH

• How ?
• When ?
• Where ?
• What ?

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HOW ?

• Full Time
• Batchelor of medical science
• Examples Stephen Repse, B med Sci
• PhD
• Higher Degree
• . 1 2 years MS or MD
• . 3 years PhD
• Part Time
• . Follow project for several years

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WHEN ?

• During your medical course a good time
• Before Specialist or GP Training Possible
• During Training a good time
• After Training Difficult

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WHERE ?

• University Department
• Research Institute
• Hospital
• At Home or overseas

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What?

• Case Report
• - Unique
• - Has a teaching point
• Series of Cases
• - Needs a comparison group
• Clinical Trial
• - How many cases necessary
• for statistical significance?
• Laboratory Project

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Select a Topic

• Select a topic for an investigative project early
  on. This is preferably done by yourself.
• Alternatively a topic may be suggested by your
  supervisor

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• Where Ideas Come From Examples
• A chance observation Harvesting the IMA with
  diathermy is OK
• Why not the radial too?
• Patients Patient suffering with Claggett
  treatment for Pheumonectomy space infection
  with pinhole leak at bronchial stump
• An original idea Cooling the A-V node should
  be protective not damaging
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• Something you have read Orotic acid protects the
  heart
• Or heard at a meeting

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• Your boss
• An experienced clinical researcher
• An original thinker
• A basic scientist

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FORMULATE AN AIM AND AN HYPOTHESIS

• Work out a specific aim
• To develop a technique for sterilising a
  pneumonectomy space
• To simplify the technique of radial artery
  harvest
• Formulate an hypothesis preferably positive
• It is possible to sterilise a closed
  pneumonectomy space
• Diathermy does not necessarily cause radial
  artery spasm

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BADLY DESIGNED EXPERIMENTS

• ..whereas for a properly designed experiment we
  can perform a valid analysis, for an experiment
  which is not properly designed we can often only
  carry out a post-mortem to decide what the
  experiment died of.
• R A Fisher, Master
  statistician

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APPLICATIONS

• Ethics
• Helps you clarify your ideas
• May cause delays so start early
• Research Grant
• Preferably do this the year before you start the
  project difficult!
• Commercial Company
• Drug firm
• Equipment company

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Give talks at any early stage

• . Where ?
• - Departmental meeting
• - Hospital meetings
• - National meeting
• - International meeting
• . Take note of the questions
• . Giving talks helps you prepare for writing
  your paper

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CARRY OUT THE PROJECT

• Pursue this special interest during your whole
  period of training
• You could include a period of full-time research
  work as part of your training period

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CONCLUSIONS

• Research is very rewarding
• I will get bored sewing coronary on grafts or
  repairing hernias for the rest of my life!
• Research experience makes a better doctor

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ALFRED HOSPITAL
BAKER HEART RESEARCH INSTITUTE
MONASH UNIVERSITY DEPARTMENT OF SURGERY
MELBOURNE
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THE SEVEN STAGES OF AN IDEA

• Norman Shumway, recalling the pioneering days of
  heart transplantation described the seven stages
  the idea went through before it eventually
  entered the field of routine clinical practice
• 1. Initial stage Wont work been tried
  before.
• 2. After successful experiments in animals
  Wont translate to man.
• 3. After 1 successful clinical patient Very
  lucky doubt if patient really needed
  transplant.
• 4. After 4 or 5 clinical successes Highly
  experimental, too risky, immoral unethical I
  understand they have had a number of deaths they
  are not reporting.

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THE SEVEN STAGES OF AN IDEA

• 5. After 10 to 15 patients May succeed
  occasionally in carefully selected cases but very
  few patients really need an operation anyway.
• 6. After a large series of successes So and so
  has been unable to duplicate their results. I
  hear that a number of their patients are now
  dying late death.
• 7. Final stage This is a very fine
  contribution. A straightforward solution to a
  difficult problem. I predicted this. In fact, in
  1939 I had the same idea. Of
• course, we didnt publish anything. We had no
  cyclosporin.
• The time frame of this evolution took more than
  20 years, between 1960 and 1982.