Strategies for Promoting Research among Endocrinologists in Private Practice

INTRODUCTION

Research in health care is essential in providing optimal- and evidence-based treatments. Although typically regarded as a domain of academic institutions, research in private practice is important and can be rewarding at various levels. The proportion of physicians in private clinical practice is more than that in academic institutes. They cater to a larger population, underlining the need for research in the private practice settings. Mentorship is another aspect that deserves attention. Accomplished mentors can guide earnest mentees in realizing their full potential.^[1] While this is well established in academic institutes, finding a mentor in private practice can be difficult.

This review aims to “help” endocrinologists currently in private practice with an interest in research by offering information and guidance needed to initiate high-quality research. Here, we have addressed some of the challenges in conducting research in private practice and attempted to provide a few solutions to simplify this task. The impetus for this article came from a talk delivered to a group of young endocrinologists, most of whom were in private practice, in a meeting organized by the Endocrine Society of India (ESI).

WHY DO CLINICIANS IN PRIVATE PRACTICE FIND IT CHALLENGING TO UNDERTAKE RESEARCH?

Despite many advantages, most endocrinologists in private practice are not actively involved in research. One of the most common reasons cited is the lack of time due to busy clinical practice. The usual perception among many clinicians is that research is someone else’s business, and academic institutions should cater to this need as they are likely to have adequate support facilities and protected time for the same. Inadequate funds to conduct research and no monetary gains are other reasons that keep private practitioners away from research. Rewards can be much delayed and the fear of not getting recognition for the hard work put in adds to the list of reasons for avoiding it.^[2] In addition, there is a lack of affiliation with academic training institutions where most research is being conducted. Hence, no access to supervision and mentorship from senior colleagues makes one hesitant.^[3] Another hurdle is in obtaining ethics clearance in private practice.^[4] Some do initiate a project and collect data; after that, there can be inertia in analyzing and publishing the data. An important reason for this is the inaccessibility of statisticians in the private practice. Although industry-initiated studies can provide financial support and other necessary guidance to initiate clinical trials in a private set up, limiting oneself to only conducting funded clinical trials is often less satisfying.^[5]

Evidence suggests that globally, research activity is considered an essential part of residency training both by the trainees and the program directors. However, even during residency, common barriers to completing and publishing research projects included lack of protected time, high resident clinical workload, and lack of experience in research skills. Around 94% of residents thought that good mentorship was essential not only to conduct high-quality research but also to ensure that the experience was enjoyable.^[6] Lack of in-depth training and hands-on experience during residency spills over into one’s reluctance to take up research activities in later years. Several studies examining attitudes toward research activities among practicing clinicians and primary care physicians have revealed a similar pattern. Although most have a positive attitude, insufficient research allotted time (76%), inadequate financial support (63%), lack of financial incentives (51%), and lack of statistical support (50%) were the usual barriers.^[7] The most common article type published by private practitioners included descriptive studies and the usual research misconduct reported was plagiarism.^[8] Keeping in mind these challenges, we have put forward a few suggestions to encourage clinicians in the private practice to participate in research.

REASONS TO PURSUE RESEARCH IN PRIVATE PRACTICE

The reasons for encouraging research in private practice are manifold. The patient population, resources, and therapeutics offered in major cities can be quite different between private and academic institutions. As private practitioners usually cater to patient population from a higher socio-economic stratum, there can be differences in the presentation and clinical course of various diseases. There is also a shorter waiting period for consultation with doctors in private practice because of which clinicians may see a different spectrum of the same disease (e.g., at an earlier stage of the illness). Hence, novel experiences and knowledge can be shared with the medical fraternity. There can be clinical problems that are exclusive to one’s practice or a particular region. Research conducted in academic settings may not answer the issues faced by clinicians in day-to-day private practice. Hence, studies in a private setting may help colleagues with similar challenges during patient care.

In the last few years, India has seen the addition of many new institutes that offer specialty training in endocrinology, taking the total number of newly qualified endocrinologists to over 100 every year.^[9] This has led to many endocrinologists moving to tier-two cities and rural areas to set up their clinical practice. As the patient population in this region may not have access to academic institutes, highlighting how to best manage patients in these settings is important. There can be unique challenges in terms of resources available and cultural and regional differences, which are worth studying. From a clinician’s perspective, research promotes intellectual stimulation and adds variety to the daily task of seeing patients. It is gratifying to travel to academic meetings and present one’s work. As a clinician, being involved in clinical research can increase the credibility of one’s practice and improve patient footfall.^[10]

HOW TO GET STARTED

Doing research over and above routine clinical practice is generally considered difficult and painful. All living organisms, including humans, are constantly motivated to move away from painful stimuli, preferably toward activities that provide pleasure. If research is perceived as a difficult and painful process, we will likely face mental blocks preventing us from actively engaging in research projects. The first step toward improving one’s attitude about research should include a strategy that converts the perception of research as a painful experience to one filled with fun and joy. Research can be enjoyable and rewarding is evident from studies assessing the attitudes of university teachers and faculty who view themselves primarily as researchers. They reported professional satisfaction in their research activities and from their ability to contribute to their university ranks through their publications. Tenure, promotions, social and academic praise, and criticism were key motivating factors for these professionals. Fear or anxiety related to research activities was not reported among these individuals.^[11] In medicine, contributions through research activity can be far more gratifying when one considers the number of patients who will benefit from significant research findings instead of the single patient across the table that one treats in clinical practice.

Once a clinician is settled in private practice, it requires extra effort to move out of the comfort zone and delve into the realm of research. The ideal time to initiate research activities into routine clinical practice is in the early phases when one is starting independently. Although plenty of stimuli are available in the literature to think about different possible research questions, it is critical to realize that those results do not necessarily apply to the patient population one is dealing with. Hence, research in “MY” setting using “MY” data should be the driving force to initiate such scholarly activities into one’s clinical practice. There are three levels in which private practitioners can participate in research: (i) contribute, (ii) collaborate, and (iii) lead.

The easiest way to start research activity is to contribute clinical data at your center to other researchers who have set up multi-center studies and let them handle the different processes involved in converting them into meaningful clinical conclusions.^[12] Another level of research commitment is to actively collaborate and get involved in all processes of the research project starting from planning, implementing, analyzing, interpreting, and publishing the study. This collaborative work can be done with the help of academic institutes, government agencies, or industry partners. The final level of involvement for a private practitioner would be to set up a center that does active research and take on the role of leading the research study and collaborating with other clinicians or hospitals.^[13] At this level, based on the clinical need, one can ask their research question and plan studies around the pressing queries one encounters in clinical practice. This is bound to yield highly gratifying results.

FINDING A MENTOR

The importance of a good mentor in fostering the right attitude toward research was briefly alluded to earlier. The Oxford English Dictionary defines a mentor as an individual who “acts as guide and adviser to another individual.” The origin of the word “mentorship” is thought to be from Greek mythology, where Odysseus asked the goddess Athena to nurture his son. She guides him disguised as an old family friend named Mentor.^[14] Mentoring has always been a part of medicine and surgery since the days of apprenticeship, but its role and value have been increasingly recognized in recent years. The image of a mentor is that of an older and wiser person and is traditionally confined to institutions where academic training occurs. However, mentorship need not necessarily be limited to arbitrary institutional boundaries.^[15] Anyone who has shared interests and greater experience in a given field, irrespective of age or gender, can don the role of a mentor. Similarly, a mentee does not always have to be a student in training; for instance, a clinical practitioner who wants to hone one’s skill in research can adopt an appropriate and willing mentor to obtain much-needed guidance and support. The relationship between mentor and mentee can provide strong academic and professional assistance as well as lead to good interpersonal relationships that extend beyond the clinical and educational environment.

ENDOCRINE SOCIETY OF INDIA ACTIVITIES TO ENCOURAGE RESEARCH

The leadership of ESI, including three past presidents, is part of this manuscript writing, and they agree in principle to its contents. ESI has already been conducting a training program in research methods for 1^st-year endocrinology students since 2015. Over the years, this program has been refined and improved into the comprehensive module that it is now. The current module includes lectures on study designs, biostatistics, sample size estimation, budgeting, grant writing, presentations and publications, and research ethics. It also provides hands-on training in planning a project, from generating a research question to developing a detailed study methodology that includes sample size estimation, application of appropriate statistical tests, and all-inclusive study budgeting. ESI also gives out nearly 20 yearly grants for endocrine research activities involving a rigorous selection process to encourage research. The society also feels that “more” needs to be done in this field and is agreeable to identifying and implementing additional strategies to promote high-quality research, with the hope that India could become the beacon nation for other lower middle-income countries in both clinical care and for building a healthy research culture.

PRACTICAL TIPS FOR FACILITATING RESEARCH

A few practical tips that can aid in initiating research practices have been collated and presented in Table 1. As mentioned earlier, research training obtained during residency may not often instill confidence to begin research single-handedly in the private sector. Hence, training programs specifically designed to familiarize one with research strategies in the private setting can be extremely useful. Many such programs are often available throughout the year, either as part-time, full-time or online courses. A few short-term programs are also conducted by various institutes periodically. Funding for research projects is another area where investigators are likely to face hurdles. Though one must work hard to write and obtain a grant, an adequate knowledge of available funding sources is critical. Some funding options have been listed in Table 1, though this list is by no means exhaustive. In addition, we have also listed 16 essential skills that one should hone to incorporate research into routine clinical practice successfully.

Table 1: Training, funding and essential skills for research

IDEAS FOR ENDOCRINE SOCIETY OF INDIA TO ENCOURAGE RESEARCH IN PRIVATE PRACTICE

An individual’s motivation is the strongest incentive to enter the realm of research. However, policy-level decisions can always pave the way to making this journey easier and more comfortable. We list below some suggestions for the ESI that could facilitate research in the private sector. If ESI could introduce these as a part of its academic initiative, the policy changes could go a long way in encouraging both junior and senior clinicians in private practice to undertake impactful research activities.

1. Facilitation of training programs in research methodology, biostatistics, and manuscript writing to expedite publication in high-impact journals (already part of ESIs annual program for 1^st-year endocrinology residents)
2. Providing funding opportunities for research by supporting grants (already underway)
3. Enabling research mentorship: ESI can provide a platform for mentees to identify potential mentors with allied interests
4. Provision of a central data management system to ease the process of data collection and having a central statistical support system for data analysis (already underway)
5. Facilitate the formation of a central ethics committee for review and approval of research projects formulated by private practitioners, as most do not have access to an ethics committee (already underway)
6. Facilitate the creation of central disease registries and actively encourage contribution from both academic and nonacademic centers, including individual private practitioners (already underway for “Disorders of sex development” and “Syndromic obesity”)
7. Encourage endocrinologists in private sector to participate in large numbers and present their research:
8. a.A special presentation category for research conducted by endocrinologists in the private sector
9. b.A separate award category recognizing their efforts.

CONCLUSION

Every clinician’s cardinal role is contributing to improving clinical evidence through quality research. This is however usually sidestepped by many in the private sector. While the reasons for the lack of active participation are plenty, there are many ways to change. There is high value in documenting the unique aspects of private practice along with the regional, cultural, and socio-economic differences in the patient population. Thereafter we can evaluate interventions in the private sector setting that can improve treatments and outcomes. By gaining knowledge and skills on research methods through training programs and accessing funding options and mentors, it is time now to move out of our comfort zone. We should show active involvement in research either by data contribution, collaboration, or even by leading innovative research projects. This seemingly daunting task of research in private practice can be made both simpler and enjoyable by acquiring some essential skills highlighted above, along with active backing from ESI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.