Clinician-Scientists in Canada: Barriers to Career Entry and Progress

BACKGROUND: Clinician-scientists play an important role in translating between research and clinical practice. Significant concerns about a decline in their numbers have been raised. Potential barriers for career entry and progress are explored in this study. METHODS: Case-study research methods were used to identify barriers perceived by clinician-scientists and their research teams in two Canadian laboratories. These perceptions were then compared against statistical analysis of data from Canadian Institutes of Health Research (CIHR) databases on grant and award performance of clinician-scientists and non-clinical PhDs for fiscal years 2000 to 2008. RESULTS: Three main barriers were identified through qualitative analysis: research training, research salaries, and research grants. We then looked for evidence of these barriers in the Canada-wide statistical dataset for our study period. Clinician-scientists had a small but statistically significant higher mean number of degrees (3.3) than non-clinical scientists (3.2), potentially confirming the perception of longer training times. But evidence of the other two barriers was equivocal. For example, while overall growth in salary awards was minimal, awards to clinician-scientists increased by 45% compared to 6.3% for non-clinical PhDs. Similarly, in terms of research funding, awards to clinician-scientists increased by more than 25% compared with 5% for non-clinical PhDs. However, clinician-scientist-led grants funded under CIHR's Clinical thematic area decreased significantly from 61% to 51% (p-value<0.001) suggesting that clinician-scientists may be shifting their attention to other research domains. CONCLUSION: While clinician-scientists continue to perceive barriers to career entry and progress, quantitative results suggest improvements over the last decade. Clinician-scientists are awarded an increasing proportion of CIHR research grants and salary awards. Given the translational importance of this group, however, it may be prudent to adopt specific policy and funding incentives to ensure the ongoing viability of the career path

Parent–child connectedness and communication in relation to alcohol, tobacco and drug use in adolescence: An integrative review of the literature

Previous reviews have highlighted parent-child connectedness and communication as important protective factors against adolescent substance use. However, these reviews focus on single substances such as alcohol. An integrative review of the literature was conducted to examine which elements of parent-child connectedness and substance-use specific communication are effective across adolescent alcohol, tobacco and drug use. Forty-two English language, peer reviewed articles were reviewed. Open communication occurs within the context of high connectedness between parents and their children. Conversations about health risks are associated with lower levels of substance use while more frequent conversations, those about parents’ own use, permissive messages and consequences of use are associated with higher levels of use. There are disparities regarding conversations about use of each substance: alcohol and tobacco are easier topics of conversation while drug use is rarely discussed. Parental alcohol and tobacco use can influence the credibility of their communication with their child. Parents should be encouraged to have open, constructive, credible, two-sided conversations with their adolescents about substance use. Interventions to improve parents’ communication skills around substance use, particularly drug use, should include the types of approaches and messages highlighted in this review, and, where possible, these interventions should include all family members

Implementing telemonitoring in primary care: learning from a large qualitative dataset gathered during a series of studies

Background: Telemonitoring for long term conditions such as hypertension and diabetes has not been widely adopted despite evidence of efficacy in trials and policy support. The Telescot programme comprised a series of seven trials and observational studies of telemonitoring for long term conditions in primary care, all with an explanatory qualitative component which had been analysed and published separately. There were changes to the models of care within and between studies and combining datasets would provide a longitudinal view of the evolution of primary care based telemonitoring services that was not available in the individual studies, as well as allowing comparison across the different conditions monitored. We aimed to explore what drove changes to the way telemonitoring was implemented, compare experience of telemonitoring across the range of long term conditions, and identify what issues, in the experience of the participants, need to be considered in implementing new telemonitoring systems.Method: Synthesis and thematic reanalysis of transcribed qualitative interview and focus group data from the Telescot programme adopting an interpretive description approach. All transcribed and coded text was re-read and data relating to the experience of the telemonitoring services, perceptions of future use and strategies for implementation were recoded into one consistent system. This was analysed thematically.Results: The combined dataset contained transcribed qualitative interview and focus group data from 181 patients and 109 professionals. Four major themes were identified, using data, empowering patients, adjusting the model of care and system design.Conclusion: Telemonitoring was valued by patients who found it empowering and convenient. This, combined with initial professional concern that increased surveillance may create dependency led to the development of a more patient led service. However, despite a number of initial concerns being addressed as the service evolved, primary care professionals identified a number of barriers to widespread routine adoption of telemonitoring, many of which could be addressed by improved system design.Keywords: Qualitative research, E-health, Primary care, Telemonitoring, Diabetes, Chronic Obstructive Pulmonary Disease(COPD), Hypertensio

Improving recruitment to clinical trials with a register of a million patients who agree to the use of their clinical records for research in the Scottish Health Research Register (SHARE)

The UK's technical ability to identify people eligible for medical research is not yet matched by a practical capability to approach them directly to ask them to consider participation in those studies. The consequence is that recruitment to research is more difficult than necessary and some projects fail. This makes Britain a less attractive location to undertake clinical research than it should be. In order to overcome this increasingly important obstacle, we wanted to develop a register of Scottish residents who wish to be considered for participation in a range of studies. This was an oral presentation given at the Clinical Trials Methodology conference 2011, 4-5 October 2011, Bristol, UK

Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units

Objectives: Various strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.Design: A qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period.Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.Results: Three themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.Conclusions: The current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality

Perspectives of patients and healthcare professionals on the impact of telemetrically supported patient self-management for chronic obstructive pulmonary disease (COPD): a qualitative study nested in the TELESCOT trial

Background: Early identification of exacerbations reduces hospital admissions and may slow disease progression. The TELESCOTrandomised control trial based in Lothian, Scotland, is investigating the impact of a tele-monitoring service for COPD with the primaryaim of reducing hospitalisation.Aim: The nested qualitative study explored the views of patients and professionals on models of telemetric service delivery and theimpact on self-management.Method: We undertook semi-structured interviews with patient and professional participants at different time points in the TELESCOTCOPD trial. Transcribed, coded data were analysed thematically. Interpretation was supported by multidisciplinary discussion.Results: 38 patients (47% male, mean age 67.5 years) and 32 healthcare professionals provided 70 interviews. Both patients and professionals considered that home tele-monitoring had the potential to reduce the risk of hospital admission. Patients generally appreciated being ‘watched over’ by the tele-monitoring, which gave them confidence to manage their own condition. They used tele-data to improving their understanding of COPD, determine their current state of health and influence decisions about their daily activities. Numerical data (e.g. oxygen saturations) were particularly valued. Changes in readings validated their decisions to adjust treatment or seek timely professional advice, and eased access to clinical care. Patients valued the personalised care provided by tele-monitoring staff familiar with their circumstances and state of health. Professionals emphasised the potential role of telemetry in encouraging prompt compliance with medically defined behaviours and attitudes, though some doubted whether it would be sufficient to overcome a perceived reluctance on the part of patients to acknowledge and take ownership of the disease. There was also a concern that ‘fixation’ on monitoring physiological parameters (especially oxygen saturation levels), promoted a medical model of the disease and might increase dependence on services in some patients. The GPs and community nursing or physiotherapy teams who provided the supporting services emphasised the importance of ‘knowing the patient’ and ‘knowing what’s normal for the individual’ in using their clinical skills to interpret incoming tele-monitoring data Conclusion: Enthusiasm for tele-monitoring as a means of facilitating self-management and thereby reducing admissions is tempered byconcerns about increased medicalisation and dependence on support services. Tele-monitoring provides data which can be used to support self-management decisions and acts as a channel for seeking professional support. The patient-practitioner relationship, personalisation and continuity of care were prioritised as important elements in delivering clinical support for tele-monitoring services by patients and professionals

Cohort profile: The Scottish Research Register SHARE. A register of people interested in research participation linked to NHS datasets

SHARE is a NHS Scotland Research (NRS) infrastructure initiative and is funded by the Chief Scientists Office of the Scottish Government. Additional funding and initiation of the spare blood retention in Tayside was supported by The Wellcome Trust Biomedical Resource Award Number 099177/Z/12/Z.Purpose: Recruitment to trials is often difficult. Many trials fail to meet recruitment targets resulting in underpowered studies which waste resources and the time of those who participated. While there is evidence that many people are willing to take part in research, particularly if it involves a condition from which they suffer, researchers are unable to easily contact such people often relying on busy clinicians to identify them. Many clinicians perceive themselves as too busy to take part in research activities. The Scottish Health Research Register SHARE adopts an approach which asks the public to consent to their data held in National Health Service databases to be used to determine their suitability for research projects. Additionally, participants can consent for spare blood, left after routine venepuncture to be automatically identified in the laboratory and stored for future research studies. Participants: Anyone over the age of 16 years in Scotland can participate. Participants are approached through a range of methods including directly at outpatient clinics and general practitioners practices, leaflets with hospital letters and personal email from employers. Findings to date: SHARE has recruited around 130 000 people. SHARE has demonstrated that it can quickly and efficiently recruit to studies, over 20 until now. In addition, it can be used to administer questionnaire studies by email and recruit to patient and public involvement groups. Future plans: SHARE continues to steadily recruit with the ambition of eventually achieving 1 000 000 people in Scotland. We are steadily increasing the number of data sets we use for identifying participants. We are adding a mobile app which will facilitate dissemination about research and allow the collection of physiological and activity data if desired. We anticipate that SHARE will soon become the main source of health research recruitment in Scotland.Publisher PDFPeer reviewe

Oximetry-supported self-management for chronic obstructive pulmonary disease: mixed method feasibility pilot project

Background: Pulse oximetry could potentially contribute to self-monitoring. NHS Lothian’s ‘Light Touch’ serviceprovided COPD patients with a self-management plan based on symptoms and oximetry. The service was overseen(though not actively monitored) by respiratory-trained community teams who were contactable by a telephonehelpline. We aimed to assess the feasibility, perceived utility and impact of the ‘Light Touch’ service.Methods: A before-and-after assessment of St George’s Respiratory Questionnaire (SGRQ), Hospital Anxiety andDepression Scale (HADS) and use of healthcare resources during the 6-month feasibility study compared to theprevious corresponding 6-months. Paired semi-structured interviews with patients at baseline and 6-months, interviewswith managers and a focus group of professionals explored perceptions of the service and self-management.Transcripts were coded, and analysed thematically.Results: We recruited 51 participants (mean age 69.7 years (SD 8.4); 21 (46 %) male). 46 participants completedquantitative follow up (2 died, 2 were unwell, 1 refused). SGRQ: 21 (46 %) participants improved by 4 or more(the minimum important difference); 12 (26 %) deteriorated by 4 or more. HADS: more participants had normalscores for anxiety (65 %) and depression (80 %) at 6-months than at baseline (51 and 64 %). More emergency therapywas prescribed during the study period compared to the previous year. Only 18 participants (39 %) contacted the LightTouch Helpline during the 6-month study.Twenty patients provided a total of 36 interviews, 8 clinicians contributed to a focus group and 6 managers wereinterviewed. Patients considered that the oximetry readings heightened awareness of their condition and gave themconfidence to make self-management decisions. Healthcare professionals valued oximetry as a tool for teaching peopleself-management skills, but were concerned that patients rarely contacted the teams for help or advice during the study.Conclusions: ‘Light Touch’ shows promise as a low-cost strategy for empowering patients’ self-management skills andreducing reliance on clinical supervision.Keywords: Chronic obstructive pulmonary disease (COPD), Self-management, Telemonitoring, Primary care,Delivery of car

Experiences of patients and professionals participating in the HITS home blood pressure telemonitoring trial: a qualitative study: Table 1

Objectives To explore the experiences of patients and professionals taking part in a randomised controlled trial (RCT) of remote blood pressure (BP) telemonitoring supported by primary care. To identify factors facilitating or hindering the effectiveness of the intervention and those likely to influence its potential translation to routine practice. Design Qualitative study adopting a qualitative descriptive approach. Participants 25 patients, 11 nurses and 9 doctors who were participating in an RCT of BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and deprivation status of the practice was sought. Setting 6 primary care practices in Scotland. Method Data were collected via taped semistructured interviews. Initial thematic analysis was inductive. Multiple strategies were employed to ensure that the analysis was credible and trustworthy. Results Prior to the trial, both patients and professionals were reluctant to increase the medication based on single BP measurements taken in the surgery. BP measurements based on multiple electronic readings were perceived as more accurate as a basis for action. Patients using telemonitoring became more engaged in the clinical management of their condition. Professionals reported that telemonitoring challenged existing roles and work practices and increased workload. Lack of integration of telemonitoring data with the electronic health record was perceived as a drawback. Conclusions BP telemonitoring in a usual care setting can provide a trusted basis for medication management and improved BP control. It increases patients’ engagement in the management of their condition, but supporting telemetry and greater patient engagement can increase professional workloads and demand changes in service organisation. Successful service design in practice would have to take account of how additional roles and responsibilities could be realigned with existing work and data management practices. The embedded qualitative study was included in the protocol for the HITS trial registered with ISRCTN no. 7261427