Research: Should more EPs be in the lab?

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The 2006 IOM report named EM research as an area critically in need of improvement. So where do we go from here?

On the surface, EM research is making strides. Today multiple research forums, including those at SAEM, ACEP and AAEM, exist for emergency medicine researchers

to showcase their projects. Many academic institutions promote research fellowships and EM researchers commonly publish in non-EM literature, including the New England Journal of Medicine and the Journal of the American Medical Association, enhancing the impact of the major EM journals. But where does our research stand in a more global context? What is the state of EM research?

To take a step backward, the more appropriate first question is this: What is emergency medicine research? If you think that the concept is a little vague, you’re in good company. Here is how the Institute of Medicine described it in their report on the state of emergency medicine, published in 2006.

“Emergency care research is a broad field of inquiry involving many disciplines and crosscutting themes. It is unlike many other areas of medical research, which tend to be defined by organ systems or types of conditions. Emergency care is uniquely defined by the urgency and location of treatment…The field of emergency care research defies easy description, and this has been proven to be one of the principal challenges facing the field as it seeks its niche in the medical research and funding establishment.”

In other words, right off the bat, emergency medicine research is at a disadvantage. Add to this the relative youth of the specialty and it’s no wonder that this field of study has been weak. Even though scholarly activity is now required for EM residents, few make research a primary goal. A survey published in 2000 found that only 5–7% of EM graduates report they plan a career that emphasizes research. This is not surprising, considering EM’s relative lack of research mentorship. In a 2001 article in Academic Emergency Medicine, the authors note that ‘emergency medicine residents have plenty of exposure to good teachers and clinicians, but little exposure to EM investigators.’

The funding barrier

Perhaps the most obvious barrier to emergency medicine research is a lack of national funds. According to the 2006 Institute of Medicine report, only 0.05 percent of training grants awarded to medical schools from the National Institute of Health (NIH) go to departments of emergency medicine. These grants average only $52 per graduating EM resident, compared to more than $5,000 per graduate received by internal medicine residents.

This marked lack of access to extramural funding may stem from a poor fit between EM research and the traditional structure of NIH research institutes, according to both Dr. Carey Chisholm, Director of the Emergency Medicine Residency at Indiana University, and Dr. William Cordell, a Medical Fellow and Clinical Research Physician at Eli Lilly.
Even with these roadblocks, emergency medicine is making significant inroads into securing grants. “We have a long way to go, but the next generation of EM researchers will be able to spend less time blazing trails and more time being productive,” said Dr. Pollack, professor and chairman of emergency medicine at Pennsylvania Hospital of the University of Pennyslvania. Dr. Chisholm, a former SAEM President, notes that the SAEM Research Fund was created with a goal of developing EM researcher skills (as opposed to funding specific projects), and initial follow-up of prior grant recipients suggests that this strategy is paying dividends. Recipients have an impressive track record of extramural funding, including NIH grants. Equally important, these individuals augment the mentor pool of successful researchers within our specialty.
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Getting your EM research off and running

{mospagebreak title=Getting your EM research off and running}

So you want to do research?
Five basic steps to get you started

  1. Find a mentor
  2. Consider getting an advanced degree
  3. Take an emergency medicine research course
  4. Attend national and regional EM meetings
  5. Focus your research interest to 1–2 areas
Steps toward funding
1)Get the faculty
To increase research productivity, more academic departments are attempting to attract dedicated research faculty. Not surprising, these non-clinical research staff have had success in securing research funding. A recent survey of EM Research Directors found that programs with non-clinical research faculty reported acquiring more grant awards (median, 4.5 vs. 2), and received greater research income than did other programs (median, $400K vs. $10K). The project further found that for programs in which grant development support was considered “adequate,” those departments had more grant revenues (median, $250K vs. $10K).
To access these resources, start simple: network. “Electronic data capture, conference calls, and message boards have made geographic proximity lose its primacy in research relationships,” says Dr. Charles Pollack, “I think we need more opportunities to meet, network, and marshal resources.” With these new technologies, it’s not hard to imagine future research projects taking on a multi-institution or even multi-country makeup.
3)Learn from the Past
Many previous studies can serve as a blueprint for successful EM research. For example, “If we could learn from the earlier cardiology trials,” says Dr. Robert O’Connor, Professor and Chairman in the Department of Emergency Medicine at the University of Virginia, “we could have an enormous impact on public health.” Specifically Dr. O’Connor notes that past large, multi-center trials with strong methodology can provide good building blocks for current emergency medicine research studies.

The road to research
According to a paper on the future of EM research, researchers need to focus, find a mentor, perform ethical research, follow through and become nationally present and known. To assist along this track, Dr. Cordell advises getting “advanced training early in one’s career rather than later when other obligations and distractions can intervene.” Dr. O’Connor suggests, “Pick a mentor, make sure it’s an area of investigation you’re interested in, consider getting an advanced degree, and try to get adequate release time to do your research.”

The future

The best research topics remain those that are the most common ED concerns. Pain management remains a fertile topic for EM research, according to Dr. Cordell, noting, “It’s the number one complaint in the ED.” He adds, “It will take at least one generation to change our attitudes—many of which are woeful—about this problem.” Other important areas for EM research, according to Drs. Chisholm and Cordell, include resuscitation research, collaborative research with other specialties investigating acute phases of disease and geriatric research to address the upcoming aging “epidemic.” Dr. Pollack notes we need to do “the best job possible in caring for patients with the complaints and diagnoses that are most common in everyday ED practice.” To that end, Dr. Pollack sees the need to focus on infectious disease emergencies, cardiovascular and neurovascular emergencies, abdominal pain, pediatrics and pain control. “It’s not just a coincidence that these areas also represent our specialty’s largest malpractice liabilities,” said Dr. Pollack. “More data means better care.”
Dr. Pollack believes that in 10 years, emergency medicine will likely have established multi-center research networks for “most, if not all of the remaining critical issues in truly emergent ED care.” Drs. O’Connor and Cordell both agree that the future of EM research is in multi-center, collaborative research. With the increased utilization of virtual networks, the internet and national meetings, multi-center trials may become more common. “I am aware of very successful research networks already established to study asthma, coronary artery disease, and pain management,” said Dr. Cordell. “There’s (literally) power in numbers.”

Dr. Breyer is the associate residency program director at Christiana Care Health System in Newark, Delaware.

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