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Research for YOs

Joséphine Behaegel has some useful advice for young 
ophthalmologists who are doing research

Josephine Behaegel

Posted: Tuesday, July 9, 2019

We all know the picture: after years of tense competition at university, you finally earned that precious residency place in your favourite speciality. You are eager to get started, to diagnose your first herpetic keratitis, to remove an ocular foreign body and to discover all of the truths of the Kanski “bible”. But then, you find out that as part of your residency, you need to have an article published too. A real article, with an impact factor and everything! GASP. An article means research. So how do we start?

If you’re very lucky, your supervisor will hand you a pre-made project approved by the ethical committee, along with a list of patients all meeting the study inclusion criteria. And right there along with it, there’s a smiling study coordinator whose new life purpose is to support you, and a statistician with plenty of spare time offering to crunch the numbers. Unfortunately, this is only a fairy-tale scenario in my experience.

I have just finished four years of clinical research as part of my PhD project. During those years I encountered quite a number of challenges that researchers may be confronted with, which I overcame through a combination of trial and error, and guidance from my promoter. Based on this experience, I am going to share with you some tips and tricks for performing research as a young ophthalmologist.

MOTIVATION IS CRUCIAL

The first thing to accept is that research is an adventure, and it is never 100% certain how a clinical study will turn out. While this insecurity may sound daunting for an ophthalmologist who likes to have everything neatly mapped out, research can be most thrilling too!

Motivation is a crucial factor. When you’re not excited about your research topic, then it may become a burden. Choose a topic that you are passionate about, and don’t let your choice be guided by your head of department who just-so-happened-to-be an expert in ocular electrophysiology, while you’re fond of the anterior segment.

Reflect on the relevance and feasibility of your research, keeping in mind some practical issues such as your available research time, the study-related costs, available funds and the prevalence of the pathology. Then, frame your research question – what is your hypothesis? What are you testing? What is new? This really helps you from getting sidetracked in the literature review.

When you do your literature review, keep it narrow. You need to thoroughly scan the field in literature but you should assume some level of knowledge on the part of the reader. Your research article is not the right place to date the origins of the first descriptions of pterygium back to ancient Egypt. Use more than just PubMed – other databases like Thomson’s Web of Science and Google Scholar can sometimes dig up an extra article. Read the references of the articles you find to see if you can hit upon more relevant papers.

Even more important than defining your research question, is the match with your promoter. A good promoter can make or break your research. Choose someone who knows the field and with whom you have a good relationship. In my case, my promoter lifted me up when results were flat or my motivation was fading.

With a clear idea in mind and a supporting promoter, it is time to write a study protocol. The clinical study protocol is the road map for your research. Writing a protocol sounds daunting but it shouldn’t put you off. Just define your inclusion and your exclusion criteria and write down the steps that you want to do. Making a nice protocol will help with your ethics request. Bonus – it will basically be the core of the methods section in your paper!

Critically, legal and regulatory requirements are still all too often neglected, increasing the complexity of clinical trials. (As if research in itself wasn’t tough enough…) Before starting, learn about the regulations and more importantly, have the right persons to guide you. Hospitals often (but not always) offer assistance via study coordinators, or even have a full-blown clinical trial centre to give you a helping hand to overcome the administrative hurdle.

Apply for ethics as soon as you can. This can take a while to secure and you may need to clarify and resubmit. You can’t do anything until you have approval, so applying early is the key message here.

ACCEPT FAILURE
Off to the actual work: performing research! A great research day is one where successful results combine with satisfied study patients. But just as in real life, sometimes things don’t happen as planned, results may be disappointing, delays can be encountered, and complications can (and will) occur. Accept failure and unexpected twists and turns throughout the process; try to learn from it and find out its root cause. And if necessary, readjust your protocol and reframe your clinical question.

Everybody acknowledges the following one, and still it is forgotten from time to time: don’t forget to save your data! Make sure to have a good backup plan. Data that are stored in only one location are not safe. Remember – patient data are highly sensitive and you need to follow strict anonymisation and the General Data Protection Regulation (GDPR) rules.

Now off to the cold-sweat-inducing part for many researchers: statistics! You might start a refresher speed course on statistics or dust off your old course notes from university. If you have access to a statistician, even better, but it is always best to consult him/her before you start for a clear statistical plan rather than dumping a pile of data in front of him/her to make sense of.

My advice here is to do as much as possible yourself. This way, you completely understand your own work, and you avoid being speechless in front of a full auditorium if the audience grills you on the statistics of your study.

Okay, results are analysed, so now it’s time to write! I’ll be honest, your very first research paper is most likely going to be a disaster. Pretty much like making a pancake. But I promise that things improve with time. Don’t try to aim for perfection when you start, and remember that the most eloquent and experienced professors around you also struggled in the beginning.

The first writing tip is to aim for a basic skeleton of a paper with bullet points, and maybe a provisional title. Then continue to a rough draft outlining your ideas. Start flexible. It doesn’t have to be perfect in the beginning. Polishing, refining and discarding text or ideas is for later on.

Writer’s block is normal and I have a few tips for dealing with it. Your first option is to have a panic attack and tell yourself that writing is just not your “thing” and spend the day binge-watching Netflix. This can work short-term, but long-term you need another solution. Set yourself small, achievable goals. Accomplishing something (even a micro-goal of five sentences) can put you back on track. Frequently, more ideas pop up during writing, and before you know it you may have finished the complete introduction. If you’re stuck in the introduction, jump to another paragraph. And if you’re really out of ideas, diving into the work of others to get some inspiration might also help.

Writing is very often done during your spare time. Therefore, I try to make writing as comfortable as possible. For me this means with an XL coffee on a Saturday morning or a glass of red wine in the evening with some music on the background. Be aware though, from the second or third glass onwards, productivity may dwindle!

Keep the references of your paper relevant. This is not school homework. You do not need to prove that you read all the articles, so don’t just throw every reference in. A reference list of 200 papers is not necessary, unless you are writing a comprehensive meta-analysis.

Once you think you have finished the article, put it aside for a day or two, then read it again with a fresh mind. You may be surprised how many (small) mistakes you overlooked before. You will probably also notice something that could be improved upon.

The last writing ingredient is – again – a good promoter or mentor. A good promoter is an experienced researcher who can revise your paper, give useful feedback, catch inconsistencies in your work and – if you’re lucky – can transform some of your repeatedly re-written sentences into a spectacular-sounding paragraph.

Then send your final draft to all of the authors involved and wait for their remarks. It is considered very poor form to send an article away with the name of an author who did not get to correct the final manuscript. If your co-author is not responding quickly, send email or text reminders. It’s annoying but you cannot cut corners here.

FOLLOW GUIDELINES
Also don’t forget that a journal has guidelines too. I spent days and nights writing my very first paper, in the most inefficient ways. An eternity later, it was written, corrected, and ready to submit! Or so I thought… Until I read the Guide for Authors on the journal’s webpage where I was instructed to reduce my word count to half of it. It took me another eternity to be able to discard parts of text that ALL seemed so relevant to me, and to which I had dedicated so much time. But experience is a good teacher and I now consistently first select my journal and have a quick look at its guidelines before writing in order to tailor the length and structure to the journal’s requirements. I believe this significantly reduced my research frustration time.

Try to choose the journal that best suits your research paper before or during writing. Don’t just shoot your article to the NEJM and work down. Think about your target audience. Who do you want to read your work? Try to send your paper to the journals THEY read.

When awaiting the reviewer or editor’s response, my advice is to be patient (it may seem endless before you get that reply), but more importantly I encourage you to grow a thick skin. Indeed, the rejection of your research paper can be very demoralising, especially for young researchers. The first time my article was rejected I cried. I couldn’t understand why someone would reject the paper I had been working on for months and had sacrificed so many good night’s sleep for. And why were they so rude? Is it against the reviewer’s guidelines to show some compassion? It made me lose some more good nights’ sleep.

As bad as the feeling of rejection was, I was also afraid to disappoint my promoter. Would she agree with the reviewers and think I did a bad job? I was surprised when she just shrugged her shoulders and immediately suggested another journal to submit my paper to.

It turns out that a rejected paper is not a big deal. If you care and believe in your work, you will always find a home for it and you’ll always find a journal that accepts your work. Now I have learned to deal calmly with any response from reviewers. I use their advice to boost my paper, and my thicker skin is very useful in real life too. (Okay, perhaps only reviewer two can still make me cry silently on the inside…)

The last essential element I want to share is that performing research involves much more than having that paper published. The experience makes you grow, not only as a researcher, but also as a resident and an ophthalmologist, and it will eventually benefit your personal life outside the hospital too. So, don’t be discouraged when you’re struggling. The only way to eat an elephant is one bite at a time!

Joséphine Behaegel is a clinical trainee at the University Hospital of Brussels and was the 2018 winner of the John Henahan Prize