Traversing

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Traversing An Obstacle Course To Research
Success A Scientific Autobiography By Kevin M.
Means, M.D.
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Undergraduate Education

• Biology major
• Exposed to some research with small projects
  working in labs
• Scraped crispy brain from rat skulls
• Cricket study
• Summer job at IBM
• Research not a strong interest yet

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Medical School

• Late 1970s
• Howard University College of Medicine
• Education was focused on clinical medicine - not
  about research
• Virtually no exposure to research and little time
  to pursue it if I wanted to
• Summer job at NIH

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PMR ResidencyRehabilitation Institute of Chicago

• Early 1980s
• Clinically focused training Clinician role
  models, mentors
• No real exposure to research
• Observations led to questions concerning patients
  and their treatment
• Why do some patients respond to treatment and
  others dont?
• What conditions favor a positive treatment
  response?
• What can we do to allow more patients to improve
  or benefit?

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PMR ResidencyRehabilitation Institute of Chicago

• Thought about the possibility of asking
  answering questions and scientifically applying
  what we learn and changing what we do.
• These thoughts were transient because there was
  no required practical exposure
• RRC now mandates a research environment
• Our residency program requires residents to
  participate in research, writing

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University of Arkansasfor Medical Sciences (UAMS)

• Clinical practice (VA) leads to more questions
  about improving care
• One question intrigued me
• What can be done for elderly patients who fall
  down?
• PCPs not sure what to do ? consult PMR
• Limited personal experience with this
• Sparse literature
• Mostly epidemiologic data some on etiology
• Limited assessment methods Nothing on
  intervention or outcomes
• Unclear what to do

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Intriguing Question Stuck With Me

• Challenging
• Needed a solution (practical)
• PMR Literature virtually absent in that area
• Found related information (e.g., gait/balance in
  stroke) but nothing specifically addressing falls
  in elderly patients
• PMR well suited to address this problem
• because of neurological and musculoskeletal
  impairment issues
• Few in our field interested in that area

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Uncharted Territory

• I realized I was in uncharted territory
• I began to think maybe this was something I could
  help answer
• My incentives
• I could help my patients and
• I could alleviate the frustration I felt in not
  knowing how to help them
• Other incentives

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What Tools Do I Need?

• I wanted to learn more about this area
• I had some of the clinical tools
• I didnt have tools as a researcher, scientific
  investigator
• I was in a Department with no researchers
• 3 senior/4 junior physiatrists none were
  researchers including the Chair (not atypical for
  PMR Departments)

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Obstacles to Research

• My Department was not research friendly
• Start-up costs (time and money)
• No research culture research not valued
• Chair, colleagues, residents
• Poor understanding of researcher needs
• Chair, colleagues
• No critical mass of investigators
• No protected time

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The Endocrinologist

• I sought help elsewhere on my campus eventually,
  I found - Robert W. Harrison
• A successful, established funded investigator,
  also a busy clinician and administrator
• Bob became my first research mentor
• We discussed my clinical problem/area of
  interest, absent research knowledge, willingness
  to learn
• Bob knew nothing about PMR, and I knew nothing
  about endocrinology

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The Endocrinologist (continued)

• Bob taught me how to think about problems from a
  research perspective Goal develop an
  application for grant support to study the
  problem
• Our research areas were so different - he
  couldnt hand me a grant and say, Here, do it
  like this
• I had to learn research process language
• Clinical Problem ? formulated into ? answerable
  research question ? incorporated into ? grant
  proposal with supporting information
• Research team building, where how to apply, etc.

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My First Research Grant

• Eventually, I was able to go through this process
  and submitted a proposal for a UAMS medical
  foundation (intramural) grant
• It proposed a researchable question
• After revision re-submission it was accepted
• I got started -1990

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My First Research Grant

• Forest vs. Trees
• To prevent falls (forest) you need to improve
  balance (tree)
• Balance must be measured (tree) to assess
  improvement
• At the time, few reliable ways of measuring
  balance
• Our funding was for developing and testing a
  device to measure balance (tree)

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Research Team

• Team vs. Individual sports
• Winning teams and role players
• During the process of my first grant application,
  I found two collaborators
• Dan Rodell, Ph.D., LCSW
• James Smith, Ph.D.

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Research Team

• Dan the PhD Social Worker
• Had some experience with the research process
  worked in the VA
• Knew nothing about PMR
• Interested in research but had few opportunities
• Dan became interested in this as a research
  project
• Dan became a named collaborator on the UAMS
  foundation grant

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Research Team

• Jim the Engineer
• We needed a machine that people could stand on to
  measure baseline balance validated by people
  with known good and bad balance
• Jim would build the balance machine
• Dan and I knew nothing about the engineering part
  of the project
• Jim had a family tragedy and was not able to
  build the machine we were months behind schedule
• Eventually, the machine was built we had to
  improvise

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My Second Grant

• Next goal Use the balance machine for a small
  pilot study apply for more grant money to buy a
  commercially available machine
• That pilot study involved an exercise
  intervention and the balance machine was used to
  measure post-intervention improvement

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Formal Training

• As I got more involved in the research process, I
  realized how much I still needed to learn if I
  was going to do major research
• Knowledge about research design and statistical
  analysis was especially lacking
• Some design help was available
• StatisticsNot many statisticians on my campus
• Some statisticians could not converse in plain
  English (covariates, survival analysis, ANOVAs,
  dependent variables, confounding, independent
  variables, etc.) I was ignorant of the terms,
  and they could not bring it down to my level.
• Then, an opportunity presented itself.

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Formal Training

• On-the-job, Off-campus (OJOC) Program inResearch
  Design, Clinical Research Design Statistical
  Analysis, U of Michigan
• An 18-month commuter program
• Weekend classes (Fri-Sun) monthly
• Intense coursework with tons of homework
• I took vacation time to go there, and paid my own
  travel expenses

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A Big Decision

• I was submitting grant applications while
  attending the OJOC Program 12 months into the
  Program, a grant I submitted to NIH got funded
  for 180K with very good scores
• I had 6 months to go with the OJOC Program to
  earn a Masters
• It would be tough to launch the NIH study and
  complete the program
• LEARN research or DO research?

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New Mentor Jerome Tobis, M.D

• For the NIH FIRST award, I needed a PMR mentor
• I met Dr. Jerry Tobis, an emeritus professor and
  physiatrist who is a researcher who had done some
  work on balance and falls
• He eventually agreed to be my mentor
• Very encouraging helped me get started
• Delighted to meet a junior colleague with similar
  interests
• An expert who could critique the content of my
  work

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PMR Research in NIH

• In 1992, few physiatrists were funded by NIH as a
  principal investigator
• PMR had researchers, but NIH was not our primary
  funding source
• No PMR institute in NIH (PMR research is part
  of NICHD)
• No PMR study section in 1992

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Gaining Momentum

• Once I answered a question, it led me to more
  questions and more projects and more grant
  applications for funding

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The Missing Piece

• I still needed a statistician to help us write up
  collected data
• Dan didnt know stats very well and Bob Harrison
  had left UAMS
• Statisticians I knew were not that helpful
• I eventually met Patricia OSullivan, Ed.D., who
  worked for the UAMS College of Nursing
• Pat and I became long-term collaborators, along
  with Dan Rodell

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Know Your Competition

• In 1990, I was aware of only 2 or 3 physiatrists
  who were doing work similar to mine
• My main competitors were geriatricians PTs
  and many of them approached falls prevention
  differently
• A race to find the best balance test for people
  who fall then the best predictor of future falls
• Then a race to develop the best intervention the
  best outcomes then side issues related to falls
• Now a race to target the intervention the most
  efficient and cost-effective way

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Know Your Competition

• Knowing and monitoring the competition helped
  me to
• Reinforce my own approach
• Avoid reinventing the wheel
• Learn from the discoveries but avoid the pitfalls
  of other approaches
• I monitored competitors by attending meetings,
  asking/answering questions, peer review
  (manuscripts grants), and correspondence

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Example Obstacle Course

• No gold standard test for balance and mobility
  in 1990
• We developed, validated, and applied our own
  balance mobility performance test
• the Functional Obstacle Course
• Development of a new test or instrument can be
  very tedious and time-consuming
• I used multiple sub-tests
• Quantitative qualitative scoring system

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Why I Do Research?

• Research wont make you rich.But
• Very rewarding
• Very challenging
• Fun!
• especially when it is shared
• small projects with students/residents
• presenting results to others who are interested

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Why I Do Research?

• Can also share findings with patients
• Example When recommending therapeutic exercise
  to prevent falls, I can say
• Research has shown this to be successful
• I have conducted some of this research myself
• I am recommending something that I have seen work
• Most patients will work with the same therapists
  same protocols
• Easier to sell patients on this based on direct
  experience

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Are You A Researcher Type?

• Most physicians are consumers of research
• Do or prescribe something that others have found
  effective
• Researchers are reality testers and need a
  questioning mindI wonder how? If? Why?
• Researchers are quality improvers and strive to
  make things better

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Research and Clinical PracticeComplement Each
Other

• I believe that I am a better clinician because
  of
• First-hand experience with improvement of care
  through conducting research
• Better observation skills from doing research
• I believe that I am a better researcher because
  of
• My work as a clinician
• Seeing patients every week who have real problems
• My patients provide new questions to research

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Researchers Need Time To Think

• Critical for a researcher to have time for
  thinking
• To put your feet up on your desk
• Ideas come to different people in different ways
• Part of research involves structuring your
  schedule so you have thinking time

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Use Your Time Wisely

• Find a mentor
• Figure out what you need
• Design what you need
• Critically evaluate what you develop
• Read the published literature to see what others
  have done so you dont duplicate what they did
  (dont repeat their mistakes) but you can improve
  on what has been done
• Network

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The Bottom Line

• The focus of my work is to improve my patients
  quality of life

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You Can Never Know It All

• The answer to one question leads to more
  questions