As a medical practitioner we would always have to query ourselves about the whys, hows, whats, and whens related to problems people present with or situations that arise as part of the discharge of our professional responsibilities. How does one get answers to these concerns and queries? The easiest way is search for published material on the subject (which nowadays is just a few taps away in this digitalized world). If we do manage to find a solution, we feel happy and get on with our lives. But, how many of us pause for a moment and give a thought to the quality of evidence for this solution; most of us take the information obtained as the “gospel truth.” Decisions based on low-quality evidence could have the potential to adversely impact the outcome—either by not improving the person's condition or hurtling him/her down the abyss of death or disability—though both being the result of a decision that was unintentional on the part of the medical practitioner.
IMPORTANCE OF RESEARCH IN MEDICINE
There are several reasons for the need of research in medical sciences; the most salient ones are outlined below.
For the Practicing Physician
Imagine a physician deciding to use prophylactic daily aspirin therapy to prevent myocardial infarction (MI) in a 50-year-old postmenopausal woman because her father had history of MI at 60 years, based on the result of a single randomized control study.
- If with this treatment, the woman does not develop MI, can one conclude that the physician's decision validates the study results?
- On the other hand, if the woman was to develop MI, would it refute the study results?
- Or if she was to develop serious gastrointestinal bleeding without developing MI, would it mean aspirin therapy is unsafe for use for prevention of MI in postmenopausal women?
These and many similar questions require an understanding of how to evaluate the strength of evidence available to be able to translate the findings into clinical practice. Understanding of research principles and methods facilitates the physician to adopt evidence-based results into their medical practice, which would not only make it more scientific but also more ethical.
Research is also needed to find a way forward to handle health problems afflicting humankind, which either have no solution, or a solution with low-moderate efficacy, or prevent the occurrence of such health maladies. The Coronavirus (COVID-19) epidemic which had its origins in China in the late part of 2019 is a case in point, where neither a vaccine for its prevention nor a drug for its treatment was available when the epidemic began. However, the attempts to characterize the virus genome and consequent efforts at vaccine development are good examples of how research is being used to address human health problems.
For Professional Qualifications and Academics
Research work is an integral part of any academic milieu, be it for award of a professional degree/qualification or for those who aspire to become part of the academic fraternity and grow within these academic institutions. The consequent academic recognition brings name and fame to the individual.
We have outlined the importance of research in medicine but for different people it probably means different things. While there are many ways of defining research, a useful way to define it is to say that it is a systematic inquiry into a particular concern or problem. The systematic inquiry process is essentially the research methodology. Understanding research methodology process is the key to one's successful journey as a practicing physician, researcher, or an academician.
The outputs of this systematic inquiry process are the thesis or dissertation. What do these terms mean?
Thesis and Dissertation
The word thesis has its origin from the Greek word “thesis” meaning “something put forth,” while the word dissertation has its origins from the Latin word “dissertare” meaning “continue to discuss.” Thesis or dissertation is a document of research findings in support of one's candidature for award of an academic degree/professional qualification. The terms have generally been used interchangeably for both award of a Masters’ degree and a doctoral degree.
The quantum and quality of research and the duration needed to complete the thesis/dissertation vary with country and university. However, there are those who wish to distinguish the two from one another. A thesis maybe understood as a tool to test the students’ understanding of their field of study/work wherein they formulate a proposition based on work done by others in the field and analyze it. In a dissertation, the student is expected to focus on an original research question and prove or disprove the hypothesis by doing the research work. A thesis submitted for postgraduate courses in medicine or nursing probably includes both the elements.
RESEARCH OPPORTUNITIES FOR MEDICAL TRAINEES
As stated earlier, key to translating evidence to practice lies in comprehending research methodology. Classroom or workshop exposure at best sensitizes the learner to the principles of research and its process, but being able to understand it sufficiently well to look at published evidence for translating into clinical practice requires one to engage in some actual research work, even though for a brief period.
Unlike overseas, where students have several opportunities for research exposure and experiences even during their graduate medical training period, these opportunities are limited in India. The Short Term Studentship (STS) offered by the Indian Council of Medical Research is probably the only opportunity that an undergraduate student has to carry out research projects under the supervision of a mentor in their own medical college without disrupting their ongoing medical training. However, not all undergraduate students get selected for the Studentship. The primary opportunity for medical graduates to experience research work in India is therefore during the pursuance of their postgraduate courses wherein the thesis related research work is an obligatory requirement for the award of their postgraduate degree.
ROLE OF THESIS IN POSTGRADUATE COURSES
The aim of postgraduate training is not restricted to ensuring the acquisition of clinical skills to work as specialist/consultant in the concerned specialty. The objectives are manifold. The thesis should empower the postgraduate student as follows:
- Enable them to critically evaluate and synthesize evidence available in published medical literature.
- To be able to translate available evidence into clinical practice.
- To be able to ask probing questions to solve clinical problems.
- To be able to enthuse some of the postgraduate students to enter the academia or research pathways.
The experience of thesis work hones the students’ skills to search medical literature systematically, synthesize available evidence, identify unanswered queries, plan a study for gathering appropriate data, get to know how to analyze their data, and finally present their work as a written document.
The thesis, eventually, will form the launching pad for those who may choose to spend a greater part of their career contributing to the growing body of medical literature by writing and publishing. The thesis also exposes them to the ethics of healthcare, which is often a neglected area in one's daily practice of clinical medicine.
How did my thesis affect me?
It improved my critical thinking, ability to look at data and its analysis, and infused a passion for academics and research and eventually launched me on that trajectory. My mentor (research guide) was an important factor in my transformation. I was also fortunate to have trained in a department which fostered and supported academic excellence, publication and research, and encouraged its postgraduate students to present papers in local and national conferences. It activated the dormant “competitive” spirit in us.
Advantage and Disadvantage of Thesis
Working on a thesis bestows several advantages to the student. It improves critical thinking of the students, helps in problem solving, would facilitate adoption of evidence-based medical practice, and improves their medical writing skills. The only disadvantage that one may put forth is time spent on thesis is relatively large and could have been put to better use for acquiring their core subject specific skills. However, in the tradeoff between the pros and cons, the advantages outweigh the disadvantages.
TRANSLATING THESIS INTO VALUABLE RESEARCH
One needs to understand the fate of the thesis after its completion. An important question is whether it should be viewed only as a passport to award of degree with the thesis left forgotten in the institutional archives? The answer to this is a definite “No.” Few theses get translated into a publication as they are not necessarily pursued any further thereafter. But there are examples wherein the thesis has become the beacon for ongoing research in the field which eventually changed practice and policy. The following experience of the author is an illustration of how thesis can translate into long-term research impacting practice and policy.
My first thesis as a mentor attempted to answer the question as to “whether room air could be used for resuscitation of newborns at birth instead of 100% oxygen”, which was driven by the observation that mouth to mouth resuscitation was being practiced successfully by primary health workers to revive asphyxiated newborns without supplemental oxygen. The question was relevant and novel but challenged by the ethical concerns of lack of any experimental or clinical data to support the proposed hypothesis. The search for this tenacious evidence to support the hypothesis led me to meet up with a researcher in another part of the world, who was independently attempting to unravel the answer to the same question in porcine models which was driven by the observation that use of excessive oxygen following hypoxia could be detrimental to the newborn due to its ability to generate free radicals. This thesis research effort was published (Ramji S et al. 1993) and translated into a journey of international collaborative research spanning three and half decades which eventually changed both practice and policy globally.
- The existing practice at that time was to use 100% oxygen to resuscitate newborns at birth.
- The thesis concluded that room air could be as effective as 100% oxygen for neonatal resuscitation, a finding that was confirmed by several clinical trials thereafter.
- Today the current policy is to initiate resuscitation in newborns with room air.
There are also other examples wherein thesis work has contributed to ongoing research and change in policy. Some of the examples include delayed cord clamping at birth to improve iron stores in infancy, use of zinc in diarrhea, lack of maternal protection against rotavirus infection in newborns, iron supplementation in exclusively breastfed infants, and serum antigliadin antibody for diagnosis of celiac disease in tropical countries.
Postgraduate students must view the thesis as an educational tool to enhance their skills to practice medicine rationally. They must enjoy this learning experience which could launch them into a successful career. To make this a stimulating experience and rather than a drudgery of doing a thesis, teachers and institutions must strive to create a conducive ambience for learning and doing.
- Cheung BMY. Medical student research: is it necessary and beneficial? Postgrad Med J. 2018;94(1112):317.
- Dzirasa K, Krishnan RR, Williams RS. Incubating the research independence of a medical scientist training program graduate: a case study. Acad Med. 2015;90(2):176–9.
- Garg R, Goyal S, Singh K. Lack of research amongst undergraduate medical students in India: It's time to act and act now. Indian Pediatr. 2017;54(5):357–60.
- Morbitzer KA, Rao KV, Rhoney DH, Pappas AL, Durr EA, Sultan SM, et al. Implementation of the flipped residency research model to enhance residency research training. Am J Health Syst Pharm. 2019;76(9):608–12.
- O'Brien JM. Conceptualizing the research culture in postgraduate medical education: Implications for Leading Culture Change. J Med Humanit. 2015;36(4):291–307.
- Personett HA, Hammond DA, Frazee EN, Skrupky LP, Johnson TJ, Schramm GE. Road map for research training in the residency learning experience. J Pharm Pract. 2018;31(5):489–96.
- Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res. 1993;34:809–12.
- Tullu MS, Karande S. Quality research in Indian medical colleges and teaching institutions: the need of the hour. J Postgrad Med. 2016;62(4):213–5.