Academic responsibility for research

Editorial Academic responsibility for research The vigour and life-blood of a specialty group depends upon rigorous, objective, scientific investigation. New ideas and new techniques which are proposed without systematic, unbiased and thorough investigation frequently serve only to clutter the literature and fail to help us treat patients. In fact, many of these new ideas and techniques have actually resulted in more harm than good for patients. Too often, innovation occurs in the operating room, is reported in the literature, and later found to be inappropriate. Unfortunately, few surgeons actually write ‘letters to the editor’ or papers indicating that their idea was poor and the technique should be abandoned. What should happen instead is that the idea which occurs in the operating room should be tested in the laboratory, carefully performed in additional patients, the results compared with standard treatment and only then should it be published. Because we see only what we know, and believe what we wish to believe, it is absolutely critical that careful investigation be done to minimise investigator bias. Who then should perform these unbiased, controlled investigations? While it is certainly conceivable that a clinician in private practice (or the sole consultant in a large district hospital) could perform investigations, it is unlikely that he would have the resources for an adequate study. Rather, it is the academic departments, units, or programmes who have the faculty and residents (registrars) who should shoulder the responsibility for these efforts. In a teaching institution, there is an increased likelihood of adequate personnel, patient population, and academic stimulation to permit good scientific investigation. Nevertheless, it is disappointingly surprising to note the lack of research emphasis in most academic units. There are a number of important reasons why controlled investigations do not occur in these programmes. Probably the most important of all is the lack of leadership on the part of the programme director, chair, or senior consultant. If the tone of the unit set by the leader is that scientific investigation is not important and is discouraged in their programme, it is literally impossible for junior faculty or residents to initiate and carry out such investigations. A second important reason for lack of investigation is related to the issue of time and ‘busyness’. By nature, surgeons are physically active people who are continually striving to increase their patient load and operating time. It is viewed as counterproductive to have time to read, think, and write protocols for prospective studies. When a surgeon is observed carrying out such activities, he is viewed as being ‘not

busy’. A second time-related issue is that many investigations must be carried out over a prolonged period of time. In units where residents and junior staff may be transient, a project which requires 3 or 4 years to complete may ‘die’ because of lack of continuity of investigators. A third major reason why such projects do not occur is the perception that there is a lack of sufficient rewards for such activities. The ‘excellent’ surgeon is continually busy seeing and treating patients, while the ‘other’ surgeons may be spending time in the library or in the laboratory. This may also translate into increased income for the busy surgeon and less income for the surgeon performing research activities. Projects which have significant impact on patient care, frequently take long periods of time to accomplish, and publications of such projects may not be forthcoming for several years. During this time, the young faculty has restricted income, little recognition by his peers, and may be stigmatised as ‘unproductive’. Finally, good research is hard. It takes a major effort to write, revise and rewrite an excellent protocol. Obtaining funding for the project is another barrier which frequently results in frustration. Actually performing the project, recruiting patients, managing the problems and set backs inherent in biological systems can be disheartening and disillusioning. The successful completion of rigorous, controlled, scientific investigations is very difficult. In summary, the group of people who are best equipped to perform good science are prevented from doing so because they lack strong leadership, that it is important for the surgeon to be busy, that worthwhile projects frequently require excessive amounts of time, that there are few financial or professional rewards for such research (especially in the early years), and finally, that good research is very hard to accomplish. So how do we solve these problems? Certainly oral and maxillofacial surgery must come to grips with these problems and make conscious efforts to solve them. I believe that the very first effort must be to epcourage the leadership of the speciality in each academic unit to look at research as an essential part of the unit’s activity. If the individual leaders become convinced that research is important, then they will expect research to be done by their junior faculty, and may, in fact, be active in research themselves. It is critical that individual academic leaders assume this responsibility. Once the academic leader is convinced, he can

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demonstrate this leadership by setting aside time and resources for the faculty and residents to perform investigations. There may be some confrontation in accomplishing this as administrators wish more surgery to be done (thereby increasing the institution’s patient service, income, and prestige) and the individual surgeon wishes to do more surgery (thereby increasing his personal income and prestige). However, if there is not dedicated time which is inviolate, the importance of research cannot be communicated to the faculty and the time to actually carry out the project will not be available. While increasing research activity may appear to go against the interests of the institution, the chair, the individual faculty, and the patient who may not receive prompt treatment, I believe that the long term goal of good scientific research to support the advancement of the specialty far outweighs these short term prizes. It is important for the individual leaders, the institutions, and the specialty to reward individuals engaged in research activity and to ensure appropriate recognition for their efforts. While salary is frequently tied to amount of clinical performance, the individual unit must devise ways to supplement the researcher’s income so that the financial burden of being a researcher rather than a surgeon can be overcome. ‘Profit sharing’ among the members of the department is at least one way to allow the research surgeon to obtain a fair remuneration. During the years of work before the publications begin, the researcher must be given some professional recognition for his work. Internal seminars and lectures, regional and district meetings as well as national and international sessions which allow presentation of preliminary data and recognition of ongoing projects are valid forums.

Nothing is more destructive than working in isolation without positive feedback and support. Since research is difficult to accomplish, it is important for the department and for the institution to help the individual researcher. Possible methods include employing laboratory technicians and nonclinical PhD personnel to help design and carry out projects. These additional staff would be supported by funds from the academic unit and the institution. While there are many reasons for oral and maxillofacial surgeons in academic endeavours not to do research, it is critical that these individuals recognise their obligations in this regard. The individual academic leadership must assume the bulk of the responsibility for past poor performance, and accept the challenge to improve this performance in the next decade. The members of the speciality must also have a change in their outlook. The very busy surgeon with hundreds of cases but no controlled trials and no publications should not be our hero. Instead, the surgeon who sets aside time each week to write protocols, fill out data sheets, collate and interpret these data, and publish the results should be our most revered members. Unless this happens, all of our efforts in expanded scope of cleft lip palate and management, oncologic surgery, and cosmetic surgery must be viewed by ourselves, as well as by our critics, as being just another opinion without any scientific basis and not worthy of serious consideration. Larry J. Peterson

Professor and Chairman Oral and Maxillofacial Surgery Columbus Ohio USA

Two new innovations for the Journal Through various ‘accidents’ of history, English has become one of the most important scientific languages. It may be wise not to dwell on the aggression and ambition which accompanied these ‘accidents’ of history! The world wide distribution of this Journal, has certainly been helped by it being written in English. Two recent developments are also greatly helped by our language. Firstly we will be exchanging the Abstracts from this Journal and the German Association’s Journal, Deutsche Zeitschrift fur Mund-, Keifer- und Gesichts-Chirurgie. For far too long the language ‘barrier’ has inhibited the English speaking countries from reading important papers published in the German Journal. I hope easy access to these summaries will go a long way to overcome

this. I am indebted to Professor Machtens the Editor, and other German colleagues who have helped and encouraged this development, as well as speaking English to me! Secondly we have now produced an Indian Edition of the Journal. Like other international journals, for example the BMJ, the production and distribution of the Journal within India, brings the costs to an acceptable local level. As an Association we have benefited from our ‘Indian links’ both from the many trainees working in the UK, as well as trainers in India, who have trained some of our Senior Registrars. I am indebted to Dr Kishore Nayak for working with the Indian Association to establish this edition. Peter Ward Booth

Editor