[Authored by Olivia Johnson, Alice Dunning and Judith Johnson]

Healthcare research can feel out of touch and out of step with clinical demands and priorities. It’s usually a slow process, often riddled with delays, and it may not address the immediate questions healthcare staff are asking.

As healthcare researchers, we have been challenged about the point and purpose of our work. After all, we’ve been asked, doesn’t research usually just confirm what we know by common sense, anyway? Aren’t the true advances in healthcare made through common sense clinical observations and logical assumption? Here, we present four reasons why healthcare research is needed (or, four ways that common sense has not been enough).

1. Widely practised treatments based on common sense clinical knowledge have been found to be ineffective (or harmful) when tested by research.

One clear example of this is the use of oxygen therapy as emergency treatment following a heart attack. For over 100 years this was considered common sense and routine, based on knowledge that the blocked artery would prevent oxygen from reaching the heart. However, in 2009 a review of research studies testing this intervention reported counterintuitive results [1]. Rather than compensating for the lack of oxygen to the heart, the review found that oxygen treatment increased, rather than decreased, the size of the area affected by lack of oxygen. These studies have started to raise debate about the guidelines for emergency oxygen treatment, challenging standard healthcare practices and moving this field forwards [2].

Reaching back further in time, in the middle of the 20th Century, we can find a similar example of counterintuitive research results in the work of Ignacio Ponseti. Ponseti was an Orthopaedic Surgeon who began researching Club Foot, a condition where one or both of a child’s feet are turned inwards and downwards. At the time, based on clinical knowledge and common sense, it was widely assumed that Club Foot should be treated surgically [3]. Ponseti, however, began to recall individuals who had had this surgical treatment twenty years later. Contrary to expectation, his research found that many of these patients were suffering from rigid, weak feet [3]. Ponseti delved into the research literature for answers, drawing on papers published as far back as 1872 [4] to develop a treatment based primarily on plaster casts [5]. His results were impressive, suggesting that 71% of feet treated with his method showed a good outcome 5-12 years later [3]. The downside was that his procedure was slow, involving phased treatment that lasted months. It felt counter-intuitive and undesirable compared to a surgical intervention which had much quicker results. Because of this, Ponseti’s approach was regarded as outlandish, and for years many people viewed him as crazy [6].  It wasn’t until the 1990s, when he had produced further promising research results and word began to spread, that his evidence-based approach became the ‘norm’.

A more current example like this comes from the field of miscarriage research [7]. Based on knowledge that the hormone progesterone is key to maintaining a healthy pregnancy, a common sense treatment for women at risk of miscarriage has been to prescribe progesterone supplements after a positive pregnancy test result. However, when it was put to the test in a large-scale study last year, this treatment was not found to be effective. Contrary to expectations, women prescribed progesterone supplements had almost exactly the same risk of miscarriage as women prescribed a placebo version of the hormone [7]. In the absence of promising new interventions for miscarriage, this result was disappointing to the many couples affected by this problem. On the other hand, it could be the evidence that researchers need to spur them on to find new answers. Let’s watch this space!

2. Healthcare research has proved that interventions that are intuitively bizarre can in fact be helpful.

Sometimes the strangest things can help, and without research, it’s hard to see how these kind of treatments would have come to light. One example comes from research into IVF (in-vitro fertilisation), where success rates continue to be disappointingly low. However, recent hope has come from a treatment known as the “endometrial scratch”. As it sounds, this is literally where the inside of a woman’s uterus is scratched prior to undergoing IVF. Although strange sounding, evidence that this may be beneficial first came from research in guinea pigs in 1907 [8]. In the past decade studies have begun to explore this treatment for boosting IVF success rates in humans. When reviewing these studies together, a recently published paper concluded that the endometrial scratch improves IVF success rates in women who have undergone previously failed attempts, who might otherwise have low chances of success [8].

Other counterintuitive treatments have come from research into physical health symptoms which cannot be explained medically. You may initially think that these problems must be rare, and that physical health problems on the whole require a medical intervention targeting the body. However, research has told us that around half of patients seen by hospital doctors may be affected by medically unexplained symptoms [9]. Armed with this knowledge, psychologists theorised that these symptoms may be psychologically influenced, and developed psychotherapeutic treatments to address them. Research testing these treatments has been promising, and a recent review of these studies found that in all cases, psychological therapy reduced the severity of medically unexplained symptoms [10].

3. What common sense would suggest is a problem, isn’t always a problem

In healthcare, it can sometimes seem that there are a lot of things that need improving. Research can just be an added burden to this, an extra job on top of the normal clinical caseload. However, sometimes research can help reduce that to-do list, showing us that some things may be fine left unchanged.

A great example of this is research into interruptions on wards. The conventional view has long held that distractions and interruptions are a threat to patient safety. They take attention away from the task in hand and break clinicians’ concentration. However, research suggests that the real picture isn’t nearly so clear. Whilst interruptions in surgical settings have been linked with deteriorations in patient safety [11], research in ward settings has highlighted the benefits of being interrupted. For example, one study found that interruptions provided important information for staff, with 11% of them communicating knowledge that improved patient safety [12]. Other research has found that interruptions may help staff to stay alert by keeping them in a heightened state of arousal and eliminating boredom [12].

Taken together, these studies oppose the common-sense view that interruptions should be eliminated in ward settings and suggest that distractions are not always dangerous. Indeed, interruptions can keep clinicians alert and informed in some settings, and efforts to remove and reduce them could have unexpected consequences. Good news for clinicians – this is one thing that can be left unchanged!

4. What is common sense to clinicians isn’t always common sense to other people, and research evidence can lead to shared knowledge.

Part of our own research focuses on healthcare staff burnout, and we have found evidence suggesting that when staff are burnt out, safety and quality of patient care suffers [13]. In our discussions with healthcare staff we have been told that our research is obvious, common sense, and common knowledge. After all, anyone working on a ward can see that this is the case. However, gathering data demonstrating this link can help to explain and describe it to the public and policy makers, who may not fully understand the daily challenges of healthcare work. Conducting this kind of research can begin to quantify this association. For example, if a nurse is suffering from moderate burnout due to difficult working conditions, just how much is the quality of the care they can provide likely to suffer? We don’t have the answer to that one yet, but it’s these kind of questions we are keen to answer. We may be stating the obvious, but what seems obvious to you or me may not be so clear to everyone else.

So where now?

It seems pretty clear to us that research is necessary. It overturns false assumptions, finds strange new answers to problems, can help clinicians focus on the most pressing problems, and can justify the resources that clinicians need.

On the other hand, we are under no false illusions that the research process is perfect as it is. It can take years to secure funding for a project that is clearly needed, years more to undertake that project, and months more again until that research may be published and publicised. In the worst cases, by the time funding has been secured for a project, the landscape of the NHS has changed to such an extent that the project needs to be overturned entirely.

A need to improve the peer-review process

It seems to us that there is one clear place these time lines could be sped up: the peer-review process. Peer review is where grants and papers are critiqued by other researchers, and it can often take several months. The reason for this? Generally speaking, reviewers are not paid, and they provide these reviews anonymously. So highly qualified, busy professionals are expected to do this in their spare time, for virtually no personal gain whatsoever. In a pressurised work environment, this crucial work falls to the bottom of a long to-do list. To us, one obvious improvement could be to start incentivising reviewers. We’re seeing steps towards this with initiatives such as offering reviewers credits (reviewercredits.com; @reviewercredits), but more is needed here. There need to be tangible rewards for reviewing that will motivate reviewers to prioritise this task.

Time to build bridges

We also think there is clear potential for researchers and clinicians to work more closely together. Researchers may have research expertise, but they need the hands-on knowledge of clinicians to know where to apply this. On the other hand, clinicians may have the best ideas, but they need to reach out to researchers to help develop that all-importance evidence base.

References

  1. Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., Weatherall, M., & Beasley, R. (2009). Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart, 95(3), 198-202.
  2. http://www.clinmed.rcpjournal.org/content/11/6/628.2.full
  3. Brand, R. A. (2009). Clubfoot: Etiology and Treatment Ignacio V. Ponseti, MD, 1914–. Clinical orthopaedics and related research, 467(5), 1121-1123.
  4. Dobbs, M. B., Morcuende, J. A., Gurnett, C. A., & Ponseti, I. V. (2000). Treatment of idiopathic clubfoot: an historical review. Iowa orthopaedic journal, 20, 59-64.
  5. Ponseti, I. V., & Smoley, E. N. (1963). Congenital club foot: the results of treatment. J Bone Joint Surg Am, 45(2), 261-344.
  6. http://www.bbc.co.uk/programmes/b06zs22x
  7. Coomarasamy, A., Williams, H., Truchanowicz, E., Seed, P. T., Small, R., Quenby, S., … & Bloemenkamp, K. W. (2015). A randomized trial of progesterone in women with recurrent miscarriages. New England Journal of Medicine, 373(22), 2141-2148.
  8. Ko, J. K. Y., & Ng, E. H. Y. (2016). Scratching and IVF: any role?. Current Opinion in Obstetrics and Gynecology, 28(3), 178-183.
  9. Nimnuan, C., Hotopf, M., & Wessely, S. (2001). Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of psychosomatic research, 51(1), 361-367.
  10. van Dessel, N., Den Boeft, M., van der Wouden, J. C., Kleinstäuber, M., Leone, S. S., Terluin, B., … & van Marwijk, H. W. (2015). Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults, a Cochrane systematic review. J. Psychosom. Res, 78(628), 10-1016.
  11. Sevdalis, N., Undre, S., McDermott, J., Giddie, J., Diner, L., & Smith, G. (2014). Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World journal of surgery, 38(4), 751-758.
  12. Sasangohar, F., Donmez, B., Trbovich, P., & Easty, A. C. (2012, September). Not all interruptions are created equal: positive interruptions in healthcare. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 56, No. 1, pp. 824-828). SAGE Publications.
  13. Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O’Connor, D. B. (2016). Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PloS One, 11(7), e0159015.

This article was originally published on 31st August 2016 on healthprofessionalofinfluence.com (a now inactive website).