Abstract
Introduction
Some of the most ambitious young physicians strive not only for perfection in acquiring clinical skills but are also working hard to become researchers. Because our workload is substantial even if we are involved only in ‘routine clinical practice', taking one step further toward clinical research usually demands a lot of enthusiasm and devotion of free time. For some young physicians from countries without an established network of research hospitals within the country and internationally, this path might be even steeper. When establishing research activities at your department, initial efforts should be made to connect with established research teams, and initiating cooperation and research fellowships could be a good initial step.
Junior perspective: Aleksandar Gavric
If I needed to decide again, I would make the same decision. From a career perspective, the decision to spend 1 year at the Hospital Clinic in Barcelona, Spain, was a good decision. We have abundant clinical practice in all fields of gastroenterology, hepatology and gastrointestinal (GI) endoscopy at my home department. However, we do not have strong tradition in clinical research. For a young physician with big ambitions for a research career in clinical medicine, the natural next step was to go abroad and try to network with established researchers. There are numerous ways of doing it. United European Gastroenterology (UEG), for instance, offers short visiting fellowships and long-term research fellowships, as also do other medical societies (European Association for the Study of the Liver (EASL), European Society of Gastrointestinal Endoscopy (ESGE), etc.). I tried to do it officially through these established channels, but the best way then appeared to be through an unofficial route. At this point I would like to encourage all young colleagues who are being overwhelmed with the advice that I also often heard myself: “Make a precise plan and know exactly what do you want to do and then do meticulous research about potential host departments and mentors. After that, talk with potential mentors and make a schedule to make the most of your time during your fellowship.” I don’t personally agree fully with this approach since over-analysis can be unproductive. In addition, in the early stages of our clinical career it is sometimes difficult to know exactly in which medical field we will subspecialize. I don’t want to confuse you, since a long-term research fellowship will demand a lot of organization and planning from your side. I would just like to suggest that a broader idea of what you might be interested in will probably be enough (for instance, endoscopy, GI oncology, etc.).
This was my approach: during a conference (I was in my 3rd of 6 years of GI residency), I approached a well-known figure in the field of hepatocellular carcinoma research and asked him whether he could connect me with someone from the gastroenterology department at their clinic, because I would like to spend a year at their department. That was how I ended up at the Hospital Clinic in Barcelona, with a team of great physicians and researchers under the mentorship of Francesc Balaguer and Maria Pellise. A whole new world of numerous opportunities opened for me. One of the striking differences that I noticed at their department was the narrow subspecialisation. While at my department each physician treats patients from quite a wide pathology spectrum within gastroenterology and hepatology, the organization of work at the Hospital Clinic enabled physicians to narrow their focus, not only from a clinical but also from research perspective.
Another piece of advice would be to pick a project that is realistic and practical for you. One that you will be able to expand further or even initiate at your own institution. Try to work with pathology that is high-volume at your department. During my stay abroad, I worked with physicians whose primary focus is diagnostic colonoscopy in high risk patients for colorectal cancer, and therapeutic colonoscopy of large colorectal polyps. Since my home department is a referral endoscopy unit, we treat quite a large number of such patients. This will enable recruitment for potential future trials and practical use of knowledge acquired during my stay in Barcelona.
I was also very privileged to work in a department in which my mentors at the Hospital Clinic were principal investigators in numerous trials, members of editorial boards of respected medical journals and members of various working groups for the development of ESGE guidelines. As a result, I became involved in numerous activities through which I obtained valuable experience for an ‘academic career take-off’. I was involved in the process of guidelines development. During this work, I learned about systematic literature research and how guidelines are developed. This was very useful experience and I have read guidelines and each recommendation more critically ever since.
Furthermore, I was involved in endoscopy research. This was another great experience since it helped me to see what it takes to organize a prospective, multicentre trial in colonoscopy research. I doubt whether this can be learned at a webinar or through reading articles, so learning by doing under good mentorship is the most efficient way. Along with direct benefits such as published papers, the ‘network’ effect is another powerful advantage. Shortly after my return to my home department, I contacted a principal investigator who had just posted a protocol for a multicentre trial at ClinicalTrials.gov. It was my mentor from the fellowship in Barcelona, Maria Pellise, whom I must thank for a positive reply and approval to participate in a well-designed prospective multicentre trial.
During my fellowship, I also did some retrospective endoscopy research and was involved in the interpretation of data from a multicentre, prospective trial. This helped to strengthen my otherwise weak skills with statistical software SPSS, as well as to revise the basics of biomedical statistics. Basic knowledge of statistics is important since it allows better understanding of research papers. In my experience, biomedical statistics are very hard to learn from textbooks and I have relearned and forgotten basic principles more than once. However, once I needed to calculate p values of my own, the knowledge settled more efficiently.
Another ‘first line’ experience was an insight into how hard it is to write a high quality medical research paper. The crucial learning aspect was very good feedback from my mentors, who regularly publish high impact factor papers. Finally, my first oral abstract presentation at ESGE days was another important experience in the world of academic medicine.
It is perhaps worth mentioning that for those who are seeking hands-on endoscopy experience, a research fellowship might not be the best option, since fellows do not usually perform endoscopy unless you arrange for a ‘practical fellowship’. However, I do not see it as a big disadvantage and you can catch up with your skills later at your home department, while experiences and connections established during a research fellowship might be an irreplaceable investment with long-term rewards.
In conclusion, I cannot emphasise enough the role of my wife. I moved to Barcelona with my wife, a 4-year-old son and our new-born baby girl. Without the full support of my wife, I would never have been able to do it. For those who already have young kids and are married, organisation will be more difficult, since you need to arrange a bigger apartment, school etc., but it is not impossible.
Do not over analyse, just do it.
Junior perspective: Gregor Novak
Yes, just do it. During this early phase of my career, a research fellowship was probably the best decision for my future path (besides saying yes to my wife). It was a life-changing experience, not just in relation to my career. Probably the biggest difference after my return to Slovenia, in addition to the knowledge I had absorbed, was the level of my self-confidence.
In the 4th year of my gastroenterology training, I left the comfort zone of clinical practice at my department to improve my research skills because I strongly believe that practicing evidence-based medicine and doing clinical research are complementary. I left for a year-long research fellowship under the mentorship of Geert D’Haens at the Academic Medical Centre (AMC) Amsterdam, The Netherlands. In addition, I was a Robarts clinical trials fellow, through which I worked with other inflammatory bowel disease (IBD) key opinion leaders.
I was part of an outstanding academic environment in which I could witness how research is done at the highest level, with all the necessary supportive infrastructure and resources. Patients in Slovenia are managed in a similar manner as in The Netherlands, in some aspects we even have some advantages (for example, access to biological treatment). However, in the field of research, we were ages behind, at least in our department. I was delighted to attend various research meetings. I met many enthusiastic and innovative people who showed me to think out-of-the-box. Nothing is impossible!
I was privileged to participate in setting up a prospective multicentric study from the very beginning, and learn every single step. I involved my home department in Slovenia in successfully taking part in the study, continuing my work when I returned back home. I was able transfer the knowledge gained in order to set up a similar study after returning. The final manuscript published in a high impact journal was part of my doctoral thesis. I would definitely advise younger colleagues to try to plan to incorporate the research work performed during research fellowships into their PhD theses. They should strive for the research to be realistic and feasible.
I was involved in writing a Cochrane systemic review. This familiarised me with the methodology, software and analysis. Being part of systemic review development allows you to read them faster and more critically. In addition, I was involved in a lot of scientific and medical writing, from a book chapter to review articles for peer-review journals. Being mentored by the best of the best greatly improved my writing skills. I was surprised how much effort and how many revisions are needed before it is finally sent to a journal.
One of the most important lessons that I took back home was the introduction to clinical trials, in which we stumble behind in my department. I got an insight into how trials on a large scale are set up and managed at the level of a clinical research organisation and how to organise a clinical trial unit in an IBD department at the level of sites. I can still learn a lot, with more than 30 ongoing clinical trials just in the IBD department of AMC.
The clinical management of patients in this research year must not be forgotten. I was able to get a glimpse of the clinical work at AMC by attending multidisciplinary IBD meetings, out-patient clinics and endoscopy suites. I gained an impression of how the medical system is organised in The Netherlands.
Leaving medicine apart, my spoken English improved considerably (unfortunately, not my Dutch because everybody was fluent in English). I got confident in giving lectures/presentations in English, since I was given plenty of opportunities.
Finally, it was a time of my life in which I really connected with my family. My wife and 3-month-old daughter (maternity leave in Slovenia lasts 1 year) joined me for this adventure. I was never on-call during the weekends so there were plenty of opportunities to travel around.
When I returned to my IBD group, I brought home several new ideas to improve our research and the clinical management of our patients. I believe it helped our group as a whole to progress further. New connections start new collaborations and we are actively involved in several ongoing multicentric studies. In recent years, we have set up a clinical trial unit and started enrolling patients in several trials.
At the end, I would just like to thank Geert for being a fantastic mentor and friend, who has also visited me in Slovenia.
I strongly believe that every medical doctor should go abroad to broaden his knowledge and perspective, establish new collaborations, gain an open-minded attitude and increase interest in research.
Should I stay or should I go? Just go.
Senior perspective: David Drobne
Almost 10 years ago, I left my country Slovenia as a young gastroenterology fellow with no research experience. Earlier, even the notion of having a small room scientific talk, facing consultants, would have frightened me. However, I remember that a year later I gave a plenary talk at ECCO (European Cancer Organisation) in Dublin, facing 2000 IBD-ologists. During that talk, when I was confronted with demanding audience questions, I suddenly felt more adult, having realized that, during a 1-year-fellowship at Leuven IBD, I had absorbed an enormous amount of knowledge from the group that had so generously received me. In other words, I sensed my improvement by seeing that I could answer all those questions, which no longer seemed difficult but, rather, interesting, inspiring and productive. I recognised that the year with the Leuven IBD group had in fact been the school of my life. Not only had I learned the general principles of research and development of ideas, the relevant lab work, statistics and writing a paper, but, importantly, I had also ascertained that clinical research was actually a way of life: interacting with other researchers, identifying motivated people at every occasion and looking for groups willing to collaborate on research projects. Initially, I thought of the Dublin podium as my only important performance ever at a big conference. I was so wrong. In a matter of years, I had several talks at major international congresses in Europe and the United States.
On returning to Slovenia, I realised that the unexplored cohort of IBD patients in this country provided a unique opportunity to establish an IBD group. So, in addition to the involvement of clinicians, we created a network of basic researchers. This enabled the slow but reliable formation of an IBD patient cohort with the biobank, thus providing the possibility of investigating important knowledge gaps in the field and to publish findings in recognised journals. One of the vital factors affecting the success of a research group such as ours, though, is the internationalisation of science, which I also learned during my stay in Leuven. This is not so just because of top expert or lab cooperation, but also due to an acquaintance with new people with similar interests. Such newly started collaboration, either through research and approach discussions or even by combining cohorts, makes exploration of clinical unknowns more efficient. Members of our group returning from fellowships abroad and bringing new ideas stimulate the group as a whole to progress further. My most important advice to younger colleagues is therefore: find an established research group of your interest and spend a year or two with them. This will be the journey of your life and you will become a different person. I owe that to all my mentors. Thank you Gert, Severine and Isabelle!