Research is an important, and formally assessed, component of physician training in Australasia. Experience in the development and implementation of clinical research is a crucial aspect of professional development in medicine. In order to continue to improve clinical practice, and hence patient outcomes, there must be an ongoing commitment to clinical research, and education to enable specialist registrars to develop their own research programs and develop the skills to critically analyse the results of research published by others. However, the interface between clinical practice and clinical research is inherently complex. There exist a plurality of stakeholders involved in the funding, design and implementation of a clinical trial, and the eventual utilization of the intervention being investigated. The transition from clinical practice to clinical research is challenging for many specialist training registrars, but ultimately, is crucial for their professional development

Broom, Alex

Broom, Jennifer

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Broom J, Broom A. Improving opportunities for research training for 
specialist registrars in Australasia.
1
Improving Opportunities for Research Training for Specialist Registrars 
in Australasia
Dr Jennifer Broom (MBChB)
Centre for Immunology and Cancer Research,
Princess Alexandra Hospital
QLD, Australia 4102 
Dr Alex Broom (PhD) 
School of Social Science
University of Queensland
St Lucia QLD 4072
Australia
 Research is an important, and formally assessed, 
component of physician training in Australasia. Experi-
ence in the development and implementation of clinical 
research is a crucial aspect of professional development 
in medicine. In order to continue to improve clinical prac-
tice, and hence patient outcomes, there must be an on-
going commitment to clinical research, and education to 
enable specialist registrars to develop their own research 
programs and develop the skills to critically analyse the 
results of research published by others. However, the in-
terface between clinical practice and clinical research is 
inherently complex. There exist a plurality of stakehold-
ers involved in the funding, design and implementation 
of a clinical trial, and the eventual utilization of the in-
tervention being investigated. The transition from clini-
cal practice to clinical research is challenging for many 
specialist training registrars, but ultimately, is crucial for 
their professional development. 
 The issue of promoting professional development 
for specialist registrars in Australia has hitherto received 
very little attention within the medical literature. With the 
exception of a number of descriptive studies addressing 
broad issues of satisfaction1, little attention has been paid 
to the professional trajectories of specialist registrars. 
Specialty-specific studies in surgery have found that doc-
tors in specialist training programs may not feel that they 
have an adequate knowledge of scientific method,2 but 
little is known about physician training and differences 
that may exist between specific medical specialist train-
ing programs. In the following discussion, utilizing a case 
of a trial initiated and organized by an Infectious Diseases 
specialist registrar, we examine some crucial issues faced 
by specialist registrars in developing and implementing 
clinical trials including: financial constraints; inter and 
intra-professional dynamics; and role-based restrictions. 
It is argued that addressing these issues would improve 
research quality, increase interest in research, and poten-
tially improve patient outcomes through the promotion of 
high quality clinical research. 
 Context - Specialist registrar training in most medi-
cal specialist training programmes under the Royal Aus-
tralasian College of Physicians includes a formally–as-
sessed research component. This involves specialist reg-
istrars submitting research projects as a requirement for 
the completion of specialist training. In Infectious Dis-
eases, registrars are required to submit three projects (e.g. 
audit, case series, clinical trial) over a three year period of 
specialist training. 
 At the time of their specialist registrar training in In-
fectious Diseases, JB designed and implemented a non-
randomised clinical trial to assess the efficacy of a simple 
intervention. The basics of the trial background and de-
sign are listed in Table 1. Ethanol lock therapy was an in-
tervention that had been used with anecdotal success at a 
previous hospital that JB had previously worked.3. There 
are two published retrospective case series demonstrat-
ing potential efficacy of the technique4,5 but no prospec-
tive studies of the intervention had been published. As 
an intervention ethanol was cheap, available and unable 
to be patented. The intervention, if proven to be effec-
tive, was likely to save time, decrease patient morbidity, 
and result in cost savings for the hospital. This was quite 
unique in the sense that most improvements in patients’ 
outcomes incur additional costs. Moreover, staff already 
had the necessary skills to implement the intervention. 
Patient numbers required were low (n=47), a relatively 
small number compared to the number of potential candi-
dates at the hospital concerned per year 
  Factors which have been observed to hinder the 
progress of the trial are discussed. It is hoped that this 
will draw attention to difficulties that are encountered 
in clinical research at a registrar level and provide some 
constructive suggestions to countering these problems.
Funding Issues
 Institutional supports - Institutional funding for 
specialist registrar research is crucial if projects are to be 
successfully developed and implemented. However, the 
provision of such support is largely ad hoc, and at times 
insufficient, presenting a major barrier to professional de-
velopment. Clinical trials are predominantly funded by 
drug companies who seek to benefit from the sale of new 
drugs once the trial is completed. This tendency toward 
economically profitable intervention has considerable 
implications for trials like that presented here. Internal 
institutional funding is usually limited and hence special-
ist registrars will not be in the strongest position to suc-
cessfully draw on this source of support, as was the case 
in this study. Despite anecdotal success of the interven-
tion and potential cost-saving to the hospital, the hospital 
did not have the resources available to support the trial. 
Weighted allocation of institutional internal funding ac-
cording to stage of training would create a more demo-
cratic process and give early researchers a greater chance 
of success in securing financial support for research.
 Commercial support - Receiving drug company 
support in clinical research is a useful means of lowering 
costs to the institution. However, drug company funding 
for small studies of non-patented, cheap interventions can 
be difficult. After considerable negotiation, minimal drug 
company funding was obtained for the study presented 
here, which allowed for the employment of a research 
nurse for one day a week for sixteen weeks. Although 
extremely limited, this funding provided much needed 
support for data collation and patient recruitment. This 
facilitated the development of a database with records of 
patient outcomes; without which the results would poten-
tially have been inadequately collated as a result of time 
constraints. However, many specialist registrars do not 
get access to funding from drug companies (nor internal 
funding support) and this can severely limit the scope and 
quality of their research programs.
 Research nurse support - The practical difficulties 
of trial design and implementation would be somewhat 
offset by adequate research nurse support. Unfortunately, 
research nurses are commonly employed by departments 
from resources sourced from drug companies for large 
nationwide or international trials, and hence are not avail-
able to assist in institutional trials that do not attract fund-
ing. Access to help of this form is usually not freely avail-
able to specialist registrars, and hence a large proportion 
of the burden of running a clinical trial will fall on a regis-
trar who already has extensive additional responsibilities 
including patient care, teaching, presentation preparation, 
and administrative tasks within their department.
Inter and Intra-professional Issues
 Negotiating adverse cases and anecdotally-in-
formed clinical practice - The issue of clinicians adher-
ing to the treatment protocol is not merely a problem for 
specialist registrars. Clinical judgment is often preferred 
by clinicians even when presented with the highest lev-
el of scientific evidence.6 For a registrar, the process of 
implementing a clinical trial is likely to be the first time 
2
Table 1: Design of the trial: Ethanol lock therapy to treat infected tunneled central venous catheters.
Trial design:
Inclusion criteria:
1. tunneled central venous catheter
2. central venous catheter associated blood stream infection
3. treating team and patient consent to trial entry
Exclusion criteria:
1. history of allergy or intolerance to ethanol
2. evidence of a tunnel or exit site infection
3. pregnant or breast feeding
4. evidence of metastatic infection
All patients received:
A. Ethanol lock therapy for four hours per day for five days to each lumen of their tunneled central venous catheter
B. Antibiotic therapy appropriate in choice and duration for the microbial pathogen isolated.
Outcome measures:
A. Blood cultures performed from each lumen of the central venous catheter one day after completion of ethanol 
lock therapy (day six).
B. Time the catheter was retained following ethanol lock therapy
Blood cultures performed as clinically indicated subsequent to day six.
in which they have had to address the issue of non-adher-
ence on the part of their colleagues. In the current trial 
it was clear in certain cases that doctors were reluctant 
to refer patients for entry into the trial because they had 
individually decided that the intervention did not work. 
This was enhanced after one case in which the interven-
tion failed. We know from the preliminary results that the 
intervention is likely to be highly successful, however, 
doctors are strongly influenced by observed complica-
tions or cases. The flow-on effect of this is mediated by 
the status of the person running the study. 
 Intra-professional hierarchies and power dynam-
ics as shaping trial implementation -  Seniority is a 
significant barrier when registrars attempt to run clinical 
trials. In cases where researchers are junior to key de-
cision makers (consultants), power dynamics can influ-
ence the degree to which the study protocol is effectively 
implemented. In hospitals, patients under a medical team 
will have a primary treating team who will consult other 
specialties for opinions, but ultimately make the final 
clinical decisions themselves. Complying with clinical 
trial protocol requires; belief of the treating team that the 
intervention being investigated has merit, understanding 
by the treating team of the clinical trial process, and ac-
ceptance of the judgment of the investigators. Registrars 
have a lower status in the hospital system than consul-
tants. This dynamic can result in practical difficulties in 
ensuring clinical concordance with trial protocols.
 The practical implications from this are that a regis-
trar contemplating a clinical trial should first of all ensure 
that he/she has the full support of his senior staff. Consul-
tants in the department from which the trial is being run 
should be proactive in promoting the trial with an aware-
ness of the influence that their status can have on patient 
recruitment and clinician concordance. 
 Trial implementation in a consultative-based spe-
cialty - The complexities of being a primarily consulta-
tive specialty are well known in Infectious Diseases and 
other consultative specialties, and will not be expanded 
on here, except to point out that this adds to the difficul-
ties in organizing a trial as an Infectious Diseases regis-
trar or physician.
Role-based Issues
 Training and professional development - Educa-
tion should be provided to specialist registrars allowing 
them to develop the skills required for collation of data 
(database design) and the need for administrative support 
should be recognized and funded. 
 Clinical service requirements place limitations on 
the time doctors can allocate to research. As a special-
ist registrar, workloads will vary between specialties and 
between hospitals. An average specialist registrar might 
work 55 to 60 hours per week. A minority of hospitals 
have protected time for research and ongoing education. 
If registrars are required to complete research projects for 
their specialist training, dedicated research time is nec-
essary given the time commitments needed for the vari-
ous elements of the research process (i.e. preparation of 
a proposal, gaining ethics approval, applying for funding, 
collating data etc…)
Conclusion
 Amongst the points raised here, we identify the fol-
lowing as key changes that would facilitate more effec-
tive specialist registrar research in Australia:
• Tertiary referral hospitals should consider providing re-
search funding directly promoting research at a registrar 
level
• Regular multi-disciplinary and inter-specialty meetings 
to communicate research plans and progress
• Promotion of the trial by consultants
• Provision of research nurse support for advanced train-
ees
• Education in study design, data collation, statistical 
analysis, and grant writing
• Protected research time
• Administrative support
 The study described above is ongoing, two years 
from initial design. The preliminary data indicates that 
the intervention is likely to be highly effective with few 
complications. A multi-site prophylactic trial is now in 
development. If conditions are improved for specialist 
registrars, more studies like the one described here will 
be performed, leading to improved outcomes for patients, 
and clinicians with more experience in research.
 Research identifying impediments to research in 
physician training throughout Australasia and under phy-
sician training schemes internationally would give useful 
information as to changes that could be implemented. 
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Correspondence
Dr Jennifer Broom (MBChB)
Diamantina Institute
Princess Alexandra Hospital
QLD, Australia 4102 
j.broom@uq.edu.au 
Phone: +61404318114
Fax: (07) 32405946
4


Improving Opportunities for Research Training for Specialist Registrars in Australasia

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Improving Opportunities for Research Training for Specialist Registrars in Australasia

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