Career Focus

Doing research

BMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7191.2 (Published 24 April 1999) Cite this as: BMJ 1999;318:S2-7191
  1. David Pencheon, Assistant Director of Research and Development,
  1. NHS Executive,IPH,University Forvie Site,Cambridge CB2 2SR

    The worst reason for doing research is because you think you should says David Pencheon. But even if you have the requisite skills in your head and fire in your belly, getting your first break can be tough. Here's how.

    We enter medical school and begin the practice of medicine with many comfortable assumptions and convenient explanations about the nature of science and the certainties of the world. It becomes uncomfortable for many of us (and a real hindrance to learning for most of us) when we gradually realise the provisional and value laden nature of most knowledge.

    Although the realisation of this uncertainty can be disturbing for those of us weaned on a simpler, more mechanistic view of the world, it is the management of this uncertainty that is such an important skill for the practice of medicine. Moreover, it is the defining feature and most important launch pad for good research. At the start of this century, Osler described medicine as a science of uncertainty and an art of probability.

    What do we mean by research?

    Research is the most obvious way to address the uncertainty that surrounds us, but what is it? Different definitions of research abound. Simply put, it is the practice of finding out more about the world around us, in order to be able to better understand it and hence better manage it. This understanding is both more valid and more generalisable when done systematically and explicitly. We are all natural researchers. It is simply a manifestation of the curiosity that our bigger brains and developing intelligence gave us when we came down from the trees. This can be seen in young children. Everything is explored, hypotheses are generated and tested, experiments occur, results are analysed, and behaviour is modified. Things start going badly wrong only when we enter formal education and our natural inquisitiveness is modified.

    At school, too many of us have been (and a few still are) exposed to a convenient and simplistic view of the world. More importantly, we are taught and examined in a way that mainly tests our ability to remember facts for exams, rather our ability to truly question, explore, and understand the world around us. Too little emphasis is placed on helping to develop our critical faculties, to question assumptions, and to challenge dogma.

    Instead, we learn to play this system of assumption and memory until we reach university. If we are obedient, this socialisation helps us through our memory examinations and into university. This is where the real researchers break through this limited mind set and develop their critical faculties. Most medical students, however, continue down memorising lane and a traditional examination system. As we meet uncertainty (often in the form of the variety of ways in which diseases present in individual patients), we are ill prepared in a system that is ill prepared to help us. Being so poorly prepared to engage uncertainty positively, some of us develop our scientific approach despite our training rather than because of it.

    The next misfortune to befall many of us is the perception of an obligation to “Do some research.”

    Why do we do research?

    At some time during our medical careers we have to decide if and how we are going to do some research. Every time we apply for a job, we have to deal with the question about research and publications. Do we choose to do research to advance our careers, because we are curious, or because a research career seems more prestigious and glamorous?

    Golden rule: do research only if you really want to. Reluctantly done research is invariably badly done research. Good research is done by people with skills in their head and fire in their belly. You can no more require people to do good research than you can require them to have a hobby. Good research comes from a dedicated and determined person working in a supportive environment. This combination is important: witness the increasing amounts of time spent by researchers merely to raise the money to continue their research, be that from the NHS R&D strategy or from sources such as the Medical Research Council or the Wellcome Trust.

    Why do so many of us have a difficult time with research?

    • We are forced into it (or at least feel forced into it)

    • We can't find the money or opportunity - a Catch 22 situation for those without a research pedigree (there is an increasing need for skills and starter grants to get people good at simply writing research protocols)

    • It is stressful to go from a valued reactive job as a clinician, surrounded by focused practical people, to a relatively lonely position as a researcher where expectations are often unclear and the progress and value of one's work are difficult to monitor

    • Training in research skills is poor. To be able develop good research skills without actually being taught them seems, for many, to be a perfectly reasonable prerequisite for entering research. This is compounded by the lack of appreciation of the range and scope of research methods and how they link with particular problems or issues.

    The building blocks of research

    The fundamental ingredients for good research are a good idea, a good method, and a determination to see it through. Research methods can range from a specific hypothesis that can be tested and proved or disproved (usually termed quantitative research) to a better understanding of human feelings and behaviour (usually termed qualitative research).

    Qualitative research is concerned with exploring why and how people feel and how they react to the world around them. Sadly, many scientists see this sort of research as rather second class research. In reality, it is often the most interesting to perform and the most revealing in its results when done well. This is mainly because the whole of human existence is subject to human behaviour. Very little in life is purely objective, and those phenomena that are can be usefully measured and eventually managed only within a human situation. The health service is not a huge clock mechanism: it is a plethora of interrelating human beings, who all display the power and perversity of that condition.

    In summary, quantitative research tends to be concerned with finding the answers to questions, whereas qualitative research is more about finding the questions to answer.

    Getting started

    It is important to ensure that you are well suited for the task of research before you get too far into the process, otherwise you risk spending three years in a laboratory wasting your time and someone else's money. Even more damaging is the unsatisfactory relation you are then likely to have with the broad world of research in the longer term.

    There are important stages to go through that, if done routinely and systematically, can help spawn fascinating and useful research results and encourage you to pursue more research. Firstly, question everything and turn issues that are unclear (both to you and everyone else) into questions. Secondly, make these questions testable and hence develop hypotheses. Thirdly, turn these hypotheses into research proposals and write them out on one side of paper in a structured way. This is a good test of whether you have a grip of the important stages of formulating the research and, at the same time, a convenient way to communicate your proposals easily to those who are in a position to help.

    It is important to appreciate the dimensions of research. For example, is this primary research (in which the unit of study is people, cells, chemicals, etc) or secondary research (in which the unit of analysis is other research)? If it is secondary research, is it personal comment or interpretation or is it rigorous (such as a systematic review and meta-analysis)? If primary research is proposed, is it a quantitative or qualitative study? If it is quantitative, is it a descriptive study, an analytical study (a case-control or a cohort study), or an intervention study (such as a randomised controlled trial)? If you are planning qualitative research, ensure that you adhere to valid research methods to explore the issue at hand. Finally, ensure that it is research you are proposing and not audit. Research (especially quantitative research) is centrally concerned with finding the right things to do, while audit is about making sure that these things are done right: both are essential steps in improving quality.

    What determines success?

    The best sort of research is done when researchers are absolutely clear about what they are trying to do and how they are proposing to do it; hence, the importance of the written research proposal. Good research is not just about the rational head; it needs to be combined with passion and perseverance. This includes the ability to communicate, both by speaking and by writing.

    Usually, only good research will get published. However, even good research can fall at this last fence by being poorly written. Make sure that you have the skills to write up (as well as perform) the research. There are many sources of advice on writing skills, such as Richard Asher's book Talking Sense. When you finally submit the manuscript for publication, it is important to include a covering letter for the editor. Briefly tell him or her what the paper is about, why it is an important issue, and why you think it should be published now in this journal. Be positive without being arrogant. Finally, ask the editor for advice if he or she considers that it needs improvement or is better published in another journal.

    Is the effort of research worth it?

    The concentrated effort of designing and executing a specific piece of research can have a large effect on subsequent individual development in terms of competence and confidence. It can also have a profound influence on the organisational culture towards uncertainty, learning, and quality improvement. Research, as Copernicus found out, has always been and should always be at least mildly subversive. It should be an exciting danger that holds the promise of improvement for the future even if it unsettles comfortable contemporary suppositions. Research may be difficult and expensive; but it is far more dangerous to blunder on assuming that your beliefs, knowledge, and practice are all optimal. To copy from no one is arrogant and dumb, to copy from one person is plagiarism, to copy from two is research. That last comment was researched.

    Further reading

    • Asher R.Talking sense. Edinburgh: Churchill Livingstone, 1986

    • Black N. Research, audit, and education.BMJ 1992;304:698-700

    • Smith R. An NHS research strategy. BMJ1991;302:1034-5

    • Evans S, Deeks J. Does research make better doctors?Lancet1994;343:58

    • Blaxter L, Hughes C, Tight M.How to research.Buckingham: Open University Press, 1996

    • Crombie I, du V Florey C. The pocket guide to grant applications. London: BMJ Publishing Group, 1998

    • Carter Y, Thomas C.Research methods in primary care. Oxford: Radcliffe Medical Press, 1999

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