The research needs of an ICM trainee: The RAFT national survey results and initiatives to improve trainee research opportunities

Abstract

Research is key to intensive care practice but it is not certain whether trainees get the research experience they want to prepare them for clinical practice as consultants. We distributed a survey via Research & Audit Federation of Trainees to 478 current intensive care medicine trainees to establish their views. We restricted analysis to regions with an 80% or greater response rate (n = 235 responses) to reduce self-selection bias. Our results indicated that the desire for research activities was high but multiple barriers exist. We suggest simple initiatives combined with engagement of trainee research networks and local Clinical Research Networks to improve trainee access to research opportunities. Greater freedom to participate in research activities could be created by broader ARCP clinical governance requirements, flexible interpretation of the FICM curriculum and support of trainees wishing to use their non-clinical time for projects. A resource detailing local research activity and appropriate contacts could help trainees plan suitable activities.

Introduction

Research training is essential to create a high quality workforce for intensive care medicine and is a priority in the FICM curriculum. ¹

Research and evidence-based medicine are key tenets of intensive care medicine (ICM) practice and clear goals for bodies invested in the future of the speciality. The Clinical Research Network (CRN) have now set a target of 80% of UK’s intensive care units (ICUs) engaging in CRN research studies. ² This will require ICUs to become more involved in research throughout the UK and is likely to involve the contribution of clinicians without formal research appointments. We have experienced trainees describing difficulty in getting research experience. Many expect to support research as consultants and take on roles as investigators for future studies. We were concerned that the creation of a research-ready new consultant workforce is not being adequately facilitated. The impact of recent changes to the ICM training landscape on trainee research activity is not known. Challenges in the shape of the new dual ICM curriculum and junior doctor’s contract could further discourage trainees wishing to undertake research activities for experience or as part of an academic pathway. Recent developments to improve opportunities include Trainee-led Research Networks (TRNs). TRNs have had considerable success providing trainees with the opportunity to be involved in high-quality, multi-centre projects. ³ The NIHR CRN are exploring ways to engage trainees more widely in future research activities. We felt that there was a need to explore the level of interest in research activities, both mandatory and those beyond the curriculum. We also sought to identify common barriers that exist and assess the view of possible initiatives designed to improve trainee access to research opportunities.

Methods

We designed a simple survey with the input of members of our local TRN and consultant stakeholders. This was piloted in the Northern Deanery among the anaesthetic and ICM trainee cohort. The data from this were used to develop questions regarding possible initiatives. Advice was sought from members of the academic community locally and nationally before finalising the national ICM trainee survey utilised in this report. We used the anaesthesia.audit platform hosted by NHS Scotland. The web-based survey link was distributed by individuals from the local TRNs affiliated with the national TRN, Research and Audit Federation of Trainees (RAFT). They targeted all current trainees with an ICM NTN over a four-week period in March 2016. Targeting methods included repeat emails, personal approaches and promotion at teaching sessions and local meetings and use of local communications such as newsletters. In areas with a poor response rate, further efforts were made including extension of the survey deadline by two weeks, promotion by Trainee Programme Directors (TPD), repeat emails and personal reminders. The sum of UK trainee numbers supplied by each TPD and Faculty of Intensive Care Medicine (FICM) was 510 in March 2016. Only 476 of these work in an area with a TRN and were sent the survey. Self-selection bias was a concern if only those individuals particularly interested in research responded. To reduce this, we planned, a priori, to restrict the final sample analysis to those regions where 80% or more trainees had responded. Simple summarising statistical methods were used to give our results. Free text comments were not subject to formal statistical methods but added insight into responses.

Results

We received 282 responses (overall 60% response rate). When considering only those regions with an 80% or greater response rate (high response regions), there were 235 responses in total from a possible 287 trainees (82% response rate). See Figure 1 for details. Respondents comprised 64% ST5 and above and 36% ST4 and below. The number of dual/single/joint CCT trainees and their parent speciality (if applicable) was not collected.

Figure 1.

Map demonstrating TRN names and logos. Geographical regions with greater than 80% response rates are shown in colour (described below with number of responses). Scotland (orange): SQUARES.NET n = 22. Northern (yellow): INCARN.NET n = 30. Yorkshire (green): AARMY & SHARC n = 35. Midlands (light blue): WMTRAIN n = 44. South & West (dark blue): OxCCARE, STAR, SPARC & SWARM n = 99. Northern Ireland (purple): AARNI n = 5. Regions with less than 80% response rate (grey).

Prior research experience

Only 9% said they had no prior research experience (Figure 2). A good proportion of trainees had undergraduate (32%) and/or post-graduate (17%) dedicated research experience. Many had been involved in portfolio studies (27%), local studies (26%) or publication (22%). Data collection for national projects such as the Royal College of Anaesthetists, National Audit Projects (NAP), had involved 40%. An encouraging 58% of trainees have received Good Clinical Practice (GCP) training with a further 18% intending to complete it. Sadly, 23% did not know what this was.

Figure 2.

Which statement(s) best describe your research experience?

Desire for involvement in research

Most trainees indicated a desire for further involvement in research with only 17% reporting that they were content with mandatory activities such as journal club (Figure 3). A third already had some research involvement planned. A desire to enhance their CV or gain experience was the top motive for this (51%).

Figure 3.

Do you wish to be involved in research?

Academic posts

Half of trainees indicated no interest in these (Figure 4). Of the remainder, concerns regarding feasibility were high. First, regarding the financial implications of taking a post (20%), and second whether their training programme or other logistic problems would make taking a post difficult (14%). Worryingly, some free text comments indicate a belief that fitting any academic post into dual training was difficult and ill advised.

Figure 4.

Are you interested in undertaking a formal academic post?

Barriers to trainee involvement in research

These were acknowledged by all but 7% of respondents (Figure 5). The top barrier (73%) was that six monthly rotations are too short to get anything meaningful achieved. Second to this (49%) was the need to complete annual audits leaving insufficient time for additional projects. Other considerable barriers were not knowing what opportunities were available to them (35%), difficulty in finding out what projects were being undertaken (47%) and who to contact at each unit (40%). Unfortunately, 19% felt that research leads were not interested in trainee participation.

Figure 5.

Do you perceive any barriers to trainee involvement in research?

Opportunities of interest to trainees

Interests were varied from involvement with established research studies to experience orchestrating their own projects (33%) or with basic sciences research (22%) (Figure 6). Trainees were most interested in opportunities to present or publish work (64%).

Figure 6.

What research opportunities would you wish to undertake?

Local and national trainee networks

Interest in TRNs was high (data not shown). Overall, 29% of our sample indicated that membership had helped them thus far. A further 15% plan to join their TRN and 31% want to know more details.

Innovations to improve access to research

Trainees indicated support of these (Figure 7). A regional resource detailing activities and contacts at each unit (a) could help trainees plan activities (64%), help them know who to contact (61%) and help them plan continuous involvement as they rotate (51%). Better identification and structure of research opportunities within each unit such as currently exist for audit and teaching opportunities (b) would help (60%). Extension of Annual Review of Competence Progression (ARCP) requirements for demonstrating clinical governance (CG) activity to include significant research activity (c) would help (69%). Finally, 43% felt greater priority in the curriculum for time spent on research (d) would help.

Figure 7.

Which of the following initiatives would increase your access to research initiatives? See text for key.

Discussion

These results come at a time of significant change to ICM training. This survey provides a snapshot of the interest, the barriers and the view of potential initiatives designed to improve access to research activities. This can be used to inform central bodies such as FICM and NIHR CRN in future developments. The regional data subsets are being analysed and presented locally by the TRNs. This is expected to inform local changes to improve trainee research opportunities. Our survey suggests that all regions could benefit from this. Post hoc analysis did not identify substantial differences between the regions in research experience, ambitions, barriers or view of initiatives. The clear desire for all types of research experience is promising and reassuring. Some of these research ambitions will require a dedicated academic post to achieve.

Academic posts

Whilst our survey was not designed to fully assess the challenges facing those considering an academic post or career or the adequacy of such opportunities, we did detect concern regarding the feasibility of pursuing such posts. Potential barriers to pursuing academic training were predicted by FICM in 2013. ¹ In the present landscape, there is a risk that academically minded trainees feel they must choose between ICM and academia and that only single speciality ICM trainees pursue the option of an academic post. We suggest the need for regular feasibility review of academic training posts within single and dual training to guide interested trainees.

GCP training

This promotes safe and ethical research practices in our ICUs. A reassuringly high proportion of trainees had completed this. The FICM curriculum does not currently specify research training methods but GCP training fulfils a number of the FICM curriculum core competencies ⁴ without adding a huge demand on trainee time.

Addressing barriers

The presence of barriers preventing trainees from reaching their goals was indicated overwhelmingly. This work does not assess whether curriculum outcomes are being met but we view these barriers as potential threats to the acquisition of necessary outcomes also.

There is likely to be considerable variation in the infrastructure of different training regions and it is for each region to formulate solutions to their barriers. Our survey sampled the view of some suggested initiatives and these findings may support ideas both locally and nationally. We have discussed these initiatives further below. A major theme from our survey free text comments was a lack of additional time to spend on research. We therefore see it as crucial that initiatives facilitate involvement of interested trainees without adding to the workload of the remainder.

ARCP requirements

A completed annual audit is the default demonstration of CG for ARCP purposes in many deaneries. The value of this has been widely questioned including within the GMC Shape of training review. ⁵ Trainees indicated support for ARCP panels extending their CG criteria. We suggest this should include significant research activity and quality improvement projects (QIP). Some deaneries already include QIP, recognising that trainees gain more appropriate CG skills from spending their free time on this type of project instead of repeated audits.

FICM curriculum

This contains a number of research and evidence-based medicine core competencies. ⁴ These outcomes are usually demonstrated by journal club, expanded case summaries and writing a publication. We would like to see other research experiences, e.g. recruiting and consenting patients as part of an RCT, as evidence for curricular competencies. This approach has been adopted recently by the trauma and orthopaedic surgical curriculum in a move to develop research ready consultants. ⁶ As patient recruitment opportunities in ICM are far fewer than in surgical specialities, this should not become mandatory for all trainees.

Non-clinical time

Trainees struggle to undertake projects due to other demands on their time. Most hospitals do not support the use of study leave or non-clinical time for research activities. We suggest that trainees could be supported in using such time for research activities much as they would be supported if they were engaging in teaching or exam preparation activities.

Advanced notice of placements

Our results highlight that six monthly rotations represent a challenge for involvement in research projects. This duration is not something we can change. We could ensure that trainees are given sufficient advance notice of rotations so they can plan research activities in advance leaving the whole rotation available for actual project activity.

Identification and structure of opportunities

The many opportunities for a trainee to gain experience with the conduct of research on an ICU are often not apparent to individuals until they are settled into their placement. We recommend that each unit should develop a means of identifying and considering the structure of research opportunities. Suitable units could nominate a trainee research lead to work in a similar way to existing audit or education leads in offering opportunities to interested trainees. Clearly, differences would exist due to the size and complexity of research projects. A fresh degree of creativity is needed to break down roles into valuable experiences for rotating trainees. Opportunities could include attending research meetings or working with research teams in recruitment, data collection or study-related procedures. Suitably motivated and supervised trainees could undertake recruitment and other activities out of hours where clinical commitments allow. This has the potential to expand the research delivery of a unit but must not become expected for fear of burdening less interested trainees.

Regional resource

Delays in planning research activity result when trainees are unable to identify local research-active consultants or find out what research activity is happening in ICUs until they start their placement. A means of looking up the research activities and contacts in each unit in advance of placements could help individuals optimise their rotation time and plan ongoing involvement in existing multi-centre studies as they rotate. The Northern CRN are finalising a regional portfolio with the dual purpose of advertising their capabilities to prospective trial leaders and industry, as well as helping trainees plan.

Role of TRNs

Trainee-led research networks have existed in anaesthesia, ICM and other specialities (notably surgery) for several years. Most output has been audits or surveys but there have been some notable successes in terms of research involvement and research training.^3,7,8

How can TRNs improve access to research?

One role is engagement with trainees otherwise not undertaking any research activity by bringing these individuals into contact with formal academic trainees and substantive researchers. Interest is generated and opportunities arise. In particular, those trainees running the networks and leading TRN projects have the potential to benefit enormously from mentoring and nurturing in their roles by local academics and other research organisations. TRNs offer mechanisms for project planning, peer-review of ideas and advertising at regional meetings as well as supporting training in research methods and facilitating funding for small projects or part-time research fellowships.

There are several limitations when considering the sustainability of trainee-involvement in ICM research. The current networks vary in size, experience, profile among ICM trainees and support from their local deanery and academics. Most TRNs have evolved as anaesthesia and ICM networks. Most of the projects have been anaesthesia related and most of the ICM trainees involved are also anaesthetists. Single speciality ICM trainees and dual trainees with other specialities outside anaesthesia might be under-represented, perhaps explaining the number of trainees in this survey knowing little about their local network.

There is a relatively small window between finishing mid-career professional examinations (such as the FRCA or MRCP) and finishing training, in which to actively participate in a TRN. Members are frequently lost as they become consultants or undertake a variety of other periods of time away from work or abroad. The high turnover and flux of membership can make sustainability and longevity difficult, potentially resulting in those taking a leadership role getting a disproportionate level of benefit.

In summary, trainee-led research networks have been a productive and exciting concept over the last few years. They are, however, only part of the solution towards increasing trainee involvement in ICM research and must not take the place of other FICM, NIHR or deanery-led initiatives due to the limitations described above.

Strengths and weaknesses

Ideally, we would have achieved an 80% response rate across the entire UK. Unfortunately, some areas of Scotland do not yet have an established TRN meaning the trainees in these regions were not surveyed. Surveys offer the best way to connect with large groups of people but unfortunately, trainees receive so many that ‘survey fatigue’ can reduce response rates unless there is motivation to engage. Some TRNs struggled to engage their trainees and it is likely this accounted for their low response rates. This lack of engagement may, in itself, be a finding. We cannot be certain that the lack of response was not due to different levels of interest, different needs or different barriers in those regions but such geographical variability seems unlikely. London had very poor response rates (18.5%). We made certain that every available means of engagement had been used (see Methods section) before accepting that further canvassing would not be worthwhile. The region containing Cambridge also suffered poor response rates (50%) despite extensive efforts and a small cohort size (16 ICM trainees). There is a degree of centralisation of research activity to London and Cambridge and trainee opportunities may be quite different in these areas compared to the rest of the country. The inclusion of responses from these regions would risk self-selection bias. By planning, a priori, to analyse only those regions with over an 80% response rate, we have reduced this. Our remaining responses reflect a wide geographical area and we feel we have attained a reasonable representative sample of UK ICM trainees.

Conclusions

The desire for research activities among ICM trainees is high but multiple barriers are present. Addressing this is important to ensure curriculum outcomes are achieved as well as to meet trainee’s individual goals and create adequately prepared consultants. Limited time seems to be the key barrier to research activity. It is therefore fundamental that initiatives allow interested trainees to pursue research opportunities without burdening those who are less interested.

The initiatives we have suggested could be implemented relatively easily. We have discussed our findings with FICM and presented our work to the NIHR CRN during the UKCCRF in June 2016. Local presentation of data is also ongoing. We hope that this work will inform changes locally and nationally which, combined with the work of TRN’S, will improve trainee research opportunities.