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Hello, good evening and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon, the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh, who accredit uh broadcasting. And I'm currently the professor in the Medical Education Research Development Unit at the Faculty of Medicine of the University of Malaya. If this is your first time, welcome. And if you're returning, thank you very much. Thank you to me all for allowing us to literally reach across the globe. Tonight, we have attendees from 40 countries and it's a very special night because I'm proud to introduce a colleague and friend at the University of Malaya. We've been talking about sharp blades last week and I think it's only appropriate that we proceed with talking about sharp minds. My colleague, Professor Doctor Van Narayanan is a consultant neurosurgeon here in the division of neurosurgery at the University of Malaya. He spent 26 years in total in medicine. 12 years as a consultant. He's published 75 journals, the citation count of 1600 an index of 14. He is the founding director of the Masters of neurosurgery Program at the University of the first Chair of Surgical Research Unit in the Department of Surgery at the Faculty of Medicine. And he is the current head of international networking globalization and strategic development at the Faculty of Medicine. He first received his initial training in Malaysia and completed his neurosurgical training at Adam bro in Cambridge in 2012. He was appointed as a consultant neurosurgeon at the University of Malaya and specializes in complex neuro oncology and epilepsy surgery. This research focuses on managing acquired brain injury across a variety of conditions including traumatic brain injury, neuro oncology, and intractable epilepsy. And he's now expanded his repertoire and interest to include neuroscience, patient safety A I and environmental impact on medicine. Van actually believes embarking on new research ideas, keeps his mind alert, sharp and active and he's deeply committed to teaching and encouraging all doctors, especially surgeons to undertake some research as part of their career. It's a privilege to introduce him and we are going to be talking about why research matters in surgery, work environment. And thank you for joining the Black Belt Academy. Thank you very much David. Uh That was very nice of you. Very kind of you. Um I am actually very happy to be here. Uh And I think I'm very privileged to have had this uh opportunity to share uh some of my little ideas over the, which I've gained over the past uh uh 1520 years. Thank you. So we'll start off. I then why does research matter in surgery? Um ok, before we start, uh I just like to share a personal anecdote um like many surgeons from uh this region, uh especially the Asian region. Um When I did my medicine research was a very small part of uh medicine. In fact, it was considered not very important, you know, it, it was more important to gain your clinical skills as quickly as possible, to learn as much knowledge as possible. Uh to, to uh translate that knowledge to clinical practice. Uh So much. So research was always uh uh pushed right to the back. Um And as I was doing my postgraduate training, research was uh for uh for quite a bit of my initial years, research was very much uh c it was only in the last uh 10 to 12 years, I would say ever since I've had the time to expand my horizons that I've, I've actually come to realize research is actually the foundation understanding research is the foundation of evidence based medicine. You know, you, you, you have to understand how research is conducted, how to evaluate the research and how you can then use that evaluation in actual practice to improve patient outcomes. And you can't do that with just book knowledge, you need to actually be in the field uh doing research. That's the best way to learn uh uh just like surgery. The best way to learn surgery is not from textbooks is by doing and the best way to evaluate research is by doing research, which is why I think research is an essential skill. We should teach our our trainees from you know, year one of medicine all the way through their postgraduate uh clinical uh training because it should be part and parcel of postgraduate training. That's, that's what I feel. So, so how does research contribute to evidence based practice? The, the primary uh way research contributes again here, when we say research, we are talking about practical knowledge and application of research. So for a surgeon who has a practical knowledge, uh we derive our evidence based medicine uh through reading journals and articles and without the adequate uh practical knowledge, uh you're gonna just believe whatever is uh uh distributed to you uh through your uh uh through your peers, through your mentors uh through the sales representatives, uh the medical pharmaceutical agents uh and sometimes through tiktok and websites, the best way to actually uh evaluate and uh uh and judge a paper or the value of a paper and how, whether you want to accept it is uh by actually knowing what is the methodology, how did they apply this uh this and whether that is transferrable to your own situation. And the, the, the only way you can do that is if you yourself have done some research, uh, in your own setting, which is why I think it's important to actually know the basics of research. It's interesting that you say that you say that and I totally agree. So, how do you get started or when you sh should you get started and again? Uh, uh, this is a question I get quite often from my trainees. When do we get started? Uh, there is no good time to start anything. Uh The earlier you start, the better it is. Uh And as soon as you, you have the ability, you should start. Um I've got uh students premed students who come to me with uh asking me if they could join my research team, they could observe what's happening and actually get very inspired by this young kids, right? Uh They haven't even gone to medical school and then they are so interested. It, it, it just inspires you, you know, your uh that, that, that whole idea that you, you are never too young to learn something new, something exciting. And um really you have to do it. You can do it at the early in your medical school. You can do it when you are starting your training, you can do it during training and you have to do it throughout your career. But uh the best time is when you actually are able to set aside a little bit of time beyond your clinical work beyond unfortunately, as surgeons, we do spend quite a bit of our time and in clinical practice. So you have to try to juggle that time for clinical practice from your educational needs and put aside a little bit of time to research uh start as soon as possible. Honestly, that's the simple basic answer as soon as you have the ability, as soon as you can find an adequate mentor start. That's the second time we've mentioned the word mental. Why is that important? And when embarking upon research, unlike clinical medicine or surgery, which already has a uh proper pathway developed over the last 100 years or so, where we've got textbooks, we've got uh medical teachers, we've got trainers who actually have been trained how to teach. Not all doctors, not all surgeons can become good teachers in research. You. And if you and this is, this applies generally across the board. Um that is one of the reasons why I thought research was a choice in my early days because I didn't find the correct mentor. Uh I did not have the appropriate environment around me, uh which encouraged people doing research. It was always uh oh, research is for the people who don't know how to operate. Uh research is for the people who, you know, who have no other choice, right? They, they, they, they have got no ways to become prominent. So they do research. It, it was always put aside. But then uh the men and a mentor is not somebody who is going to teach you step by step. That's a teacher, a mentor guides you a mentor who shows you the correct pathway. You have to do the work yourself. But the mentor is able to kind of nudge you along the correct pathway. And that's what happened about 1012 years ago. Initially, I found a mentor here, uh president who was my initial trainer in neurosurgery. He was the one who first prompted me to uh take up research. And he is uh his idea of pushing me was, you know, if you want to do all your specialty and subspeciation, you need to have research papers. Otherwise you can't go to uh Cambridge, you know, they are not going to accept you. So it was sort of a uh uh uh uh you know, uh push factor, you have to do this, otherwise you can't uh continue with your uh uh with your post graduate training. And similarly, as I went to, when I went to UK, and I was introduced to this whole environment, which was very much different from here. Research was part of the culture in UK. Uh my trainees, my fellow colleagues, you know, it was something they discussed on a day to day basis in the, in the day to day clinical practice that kind of gave me uh uh it, it opened up my horizons. And again, I found a couple of mentors there. Uh and subsequent to that. I have been in touch with a number of them throughout my whole career. And these are people who actually uh initiate your journey, guide you along the way, nudge you along the correct path. And when you are tired or when you feel like, you know, you can't really see the end of the tunnel, they are the ones who are gonna tell you. Don't worry, there's light at the end of the tunnel, just walk forward, just take one step at a time and you need that. You really need people. Like how do you, how do you find these people that they don't walk around with a sign saying I'm a research mentor? How, how do you identify a good? Again, I can only talk about my own personal experience. Um A lot of this is rip. I II don't believe so much in luck. Uh Luck is basically a combination of hard work and proper planning, right? You have already, you are in the correct place, the correct time you have already put in the work. So when that opportunity comes, you are able to grab it, that's basically uh serendipity. And II, guess I it took me a little bit of time, but by the time I reached that, that point, I was ready, I found a person who was suitable. I kind of latched on to that person who was my mentor. And subsequently it, you know, as as time goes on it becomes easier to identify these other people who are going to help you. Uh And these are the people you should actually use as your example to learn from. And uh I guess it changed it. How do you find a person differs from people to people? But that's what happened to me. That's my personal experience of finding my own mentor. So it's almost like when the student is ready, the master will appear. Absolutely. I II think, I think you just summarized uh everything I said in the last two minutes in one sentence. Absolutely. Yes. So, so what challenges might you face as a new researcher? And how do you, how did you, would you recommend you overcome them? The main challenge in starting research is the lack of uh appropriate knowledge in the field. Uh The lack of a correct environment, it's not so much, you know, people say uh it's the lack of funds, it's the lack of uh research assistance. It's the lack of equipment. That's not it at all. It's very much your own knowledge, your own motivation and your ability to uh to look beyond that narrow box. You have been trained as a medical student, as a surgeon to think down a small silo. You have to widen your horizon, you have to look beyond your own fields. You have to be able to accept new ideas. You have to be able to question. I find questioning is a brilliant way of starting on the research. In fact, that's what I tell my students. You go to a conference, don't just sit down and you know, try to memorize what they are telling you. Uh speakers talking to you about, ask questions, ask him. Why do you say? So, what is your evidence? Where did you get that information from? How does that happen? Why, what would happen if something changes? And that's how you start. You, you have to have a critical mindset and that, that's part of why research is important. It develops your critical mindset and it's very essential for a surgeon. You can't go unquestioning into uh a surgery or into a uh into a patient care because you want to ask, am I doing the correct thing? Uh is there a better way to do it? And to develop that critical mindset research is a, is a really good tool. So a lot of people think about research would be thinking about sitting at a bench with test tubes and pads. Perhaps you could elaborate a bit further on what research actually means. So and different types. There, there, there, there are so many different types of research. Uh The the most basic and fundamental is what you just described the test tubes, labs, uh genetic research, uh proteomic uh sitting down tinkering with uh various compaction. That is probably what people think of as scientists, basic science research. However, there is a huge area beyond that, you've got clinical research, which uh which involves everything from uh epidemiology, patient populations, uh evaluation of clinical treatments, uh new surgical techniques, uh new interventions, these are all a variety of clinical research. Most often they are observational interventional. Uh and you can have them either retrospective perspective as in, you know, you can look at previously available data or you can look into future data. So there's a whole variety of clinical research. Beyond that, we have got translational research which actually bridges the gap between basic science and clinical application. And, and, and then there is the other big group which actually we saw in action in the last four or five years, health services and policy research. Uh when the pandemic hit, it was research which uh which was involving public health services that actually helped us identify where the uh the pandemic virus was coming from how to contain it. Uh you know, the necessity of developing vaccines, the next of uh of uh uh vaccinating large groups of people so that it does not spread these were ideas that from public health research, which is extremely important in uh in, in large groups of diseases. Uh So there are variety of research. It's not just about test tube, it's not just about sitting in a dusty lab with a lab coat trying to think right? And, and, and if you, if you open your mind a little bit every day, every patient you can convert to a research. It, it's, you basically uh the idea of looking at a new patient who comes in with a problem which you can't. I uh you know, put your finger on, you go back and read the journals, you look at what's happening. That's, that's uh the essence of research. II do like a quote that was from professor uh B VC who headed up the Thrombosis Research Institute where I did my research. He said it's called research. Not search, it's research because now you have to do it properly and ask the right questions. A lot of people when they embark upon research, think that is looking for something novel, something different or something that will be published in nature. That's not the case, is it? Yes. Unfortunately, a lot of people when they start off, they think uh my ideas are uh are not really normal. I'm not going to be able to publish a nature. I'm not going to win the Nobel Prize. Uh That is true to a certain extent, but you don't need all research to be like that. Research is small building blocks. We need to start from basics, we need to start building one step at a time only then you're going to reach the heights. And every bit of research is important. Even that audit you do in the ward to find out the source of infection is going to help your patients in your ward. Uh just because you can't publish it in nature or even in your own local journal does not mean it's not useful. Even the research that is negative, the research that actually gives you ap value of larger than 0.05. And because of that, it's useless is actually useful because it tells you look, if you look down this research question with the appropriate sample size, that is then maybe it's not going to work. You should look the other way you should look at different directions. It actually uh allows people to uh to critically evaluate the approach they have and maybe change the directions. So research as much as we want it to be published in nature and New England, I think every research is important. E every research adds on knowledge. Uh II, we shouldn't just push it away as long as it's done appropriately. It is useful. I agree with you. There appears to be a bias in generals to publish positive outcomes. Not I tried doing this and it didn't work. So the you don't seem to have journals focused on. I tried this where the methodology was perfect. You can learn from that but it didn't work. I II absolutely agree because you see there, there are two types of research that don't get published very often. And one is what you just described uh uh uh a research which was done methodologically sound uh and has had adequate sample size. It gets a negative result. It is pushed away similarly application studies, you know, somebody has done something good in uh uh for instance, in UK or us. And we would like to replicate it in Malaysia or Singapore. And that replication study doesn't get published because the editor says, oh, this has already been done. We don't need this anymore. Both of those are wrong in my view primarily because every negative study adds on value. It adds on as I explained earlier, it adds on value in the sense that we know that maybe in a methodologically sound way if this is done and it doesn't give you value. We should look at a a different aspect of it instead of letting other people do the same mistakes and these resources. So that's one similarly replication studies, replication studies are very important in that it actually tells you uh these, let's say these drugs, this certain condition actually works and it works for my population, which actually has got a diverse genetic and cultural and social and other differences from a population which is primarily Caucasian or African in nature. And, and for that purposes, replication studies are equally important. We do need to find some you. Uh I do, I mean, uh I think we are improving in that sense. We have got a lot of online journals, there are online platforms, curious and a few others which actually now publish uh negative uh negative result journals. And negative result articles as well as replication articles. So it is possible we just have to find the proper avenue platform. So how would you go about finding a research topic? Uh The research topic it depends on at which stage you are asking. Remember earlier, you asked me, when do you start research? I think you should start as soon as possible. But uh uh what kind of research you're gonna do differs from your, the, the the at the point where you are, if you are a junior trainee, uh let's say you just finished medical school, you are waiting for your uh ao for you are waiting to become an intern. Uh At that point, the best way to look for is look around you. What are the problems you see around you? Is there a a source of infection? Is there certain interesting cases that come through your clinic? Uh You can start with the simplest ones which is case reports. Uh There are lots of people who say case reports don't make sense anymore. We've got too many case reports, but I don't think so. I think case reports are interesting in that you find that one single case, you actually go in depth, you find the points that make a difference. Uh You do a good literature review and you actually assess and establish this is how we should improve ourselves in managing this case is a good addition to your knowledge base. Right. So good case reports written, well analyzed research uh with proper literature review are actually very useful. And uh uh that's what a junior trainees should start with. Start with simple uh case reports, start with audits, audits again. A lot of people dismiss audits because audits are just uh descriptive numbers you're taking, it's not so sexy. It doesn't have the Kaplan Meyer. It doesn't have the Spider web chart or the box plot or whatever they are looking for. You don't need that. What you need is you need to establish that I have done an audit in my hospital and I that uh hand hygiene is directly correlated with the number of patients who are developing ventilator acid pneumonia. And so I have now found this is the II, I'm just giving you the example of the cuff. This is the problem in this particular ward. So we if we change that we put in additional, I don't know alcohol swabs or something or other. And that way we can reduce it. So that audit actually changes the lives of patients. It actually makes a difference. So start with simple things like case reports, audits, you can then move on to more uh uh heavier material like uh retrospective trials, retrospective trials usually depend on databases. So either precollected databases or you collect the database yourself. So having those information you can actually now analyze, remember we also have got more tools now than we used to one of the big problems I faced when I first started research other than funds and everything else was statistics. I was never, you know, it was never a strong suit of mine and we weren't thought about the appropriate use of statistics. So I always found it very scary to approach statistics. But we have got so many tools. Now. A I has taken over a lot of these things used judiciously. We can actually use various tools Softwares. Uh And, and you actually have got proper guidance on how to use the software appropriately and you can do their statistics or a statistical analysis to find out what actually makes a difference. So you progress from that, that's how a trainee should progress. They should find. Uh again, how do you find a research topic? You should find a gap in the literature, you should find a problem in your ward. You should find a question that's been uh you know, kind of niggling around your brain. Uh You should look at what the speakers in conferences are talking about. You should look at what are the current problems in the world. You look at the environment, you look at sustainability, you look at uh you just don't look at medicine, you look beyond, you look at uh uh academic uh health care uh related issues. So there's so many questions, ask the questions and then maybe you can list down what are doable, what are not doable and take it from there. So a simple question, why looking around your environment and looking at your patients is a good start. So how would you actually refine the question into something more focused and more answerable? The OK, these, these are much easier answers because there are already a lot of tools available online. Um Again, just like A I among the things that has helped a lot of people embark on research now is the various resources available online. You just go online, you type out how do I start a research? You can find enough uh websites and videos actually explaining this to you. So let's say you have now picked up a question. I have got this problem. I would like to know why this certain group of patients have got this typical cancer uh in a certain part of their liver or lung. So you have that question. Now, you need to frame it uh in a, in a way which is answerable because a research question. The 1st 1st step is to ensure that it's answerable. If it's not answerable, if it's not uh possible to do, then you there's no point in back on it when I mean, answerable, you must see whether the research is feasible in its first step. So uh you have to have available resources, you have to have available time, the patient population must be correct. Uh You must be able to access the data necessary So that is feasible. It must be an interesting question. If it's not interesting, people are not, unfortunately in this world they are not going to publish it because if it's something really boring, they're probably gonna go. Uh, right. Uh, I'm not really interested in this. Uh, uh, let's look for something different. Right. So you want to make it interesting, you want to make it, uh, normal because it has to be, uh, uh, to, to, we did talk about novelty earlier and I said, you don't always have to be no, but a novel person is always much more interesting than, uh, than something that's already been answered. So you want to make sure it has not been answered. You want to try to confirm or refute previous findings or you want, maybe I want to try that in a new setting, I guess, or a new population, a new, a new area. There's so many ways to make a question normal. You look at different populations, you look at different time spans, you look at a, uh, a longer period of time so you can make it normal. You have to make it ethical. The, the this is essential. There is no way to go around this bit about ethics. Uh, whatever we do as physicians, our first rule should be, do no harm. If you think your research has a possibility of being unethical, please do not embark on it. There is no excuse for that at all. II don't really have to emphasize it more than this, but it is essential. And the final, usually the final part I use is relevance. So a research must be relevant, it must advance your scientific knowledge, it must influence your clinical practice. Uh It could possibly impact uh your uh impact your health policy or maybe even guide future research. But there must be some sort of uh uh relevance to that research. So all of this uh you can use the acronym fine stands for F in er which is basically feasible, interesting novel Ethical Relevant. And once you use this, you'd be able to uh to to, to map out the question in a much more uh much more. How should I say answerable way? Because that's that's essential. Your research question has to be answerable. I heard you describe the po framework to structure your research question. Could you explain what that is, please? So we usually use a the final criteria to develop the research question. But once you have developed the research question, you need to identify how to implement that research. So when we want to implement a research, we can use the PCO PCO acronym. The PCO acronym basically stands for P IC OTP for patient population or problems I for the intervention C for comparison, O for outcome and T for time. So usually what we use is uh this, this, this acronym is used for uh to to, to uh look at how we can implement a certain study. Let's take for example, a randomized trial of conservative versus surgical management of acute appendicitis. It's quite simple. So you would want to see II as, as a general surgeon, I would like to know whether conservative versus surgical management, which is better for acute appendicitis, right? And I want to conduct a randomized controlled trial. So in this case, the key of patient population is patients with appendicitis. The intervention is conservative management and the comparator is surgical management. You could, I mean you could play around with that but usually be one or other. The intervention is conservative management. The comparator is surgical management and the outcome is either resolution of symptoms or reduction in morbidity. And by doing this, you have actually clarified what the methodology of the research project itself is. The other word, I'd add to all of this. You gotta be 100% honest in reporting and documenting your findings because the pressure of publishing positive results of that, I think the temptation is to light up and make it look better than it actually is. So honesty is a foremost in that honesty is important in every aspect of our career. As physicians, you have to be honest with yourself, as you do your work on a day to day basis, you have to be honest with your patients as you provide them, the pros and cons of certain diseases and certain interventions, you can't buy your intervention to something you are familiar with. Just because that's what you're good at. That is not honesty, you, you have to be honest. This is good. This is also equally good, but I do not do this, right? Uh Similarly, honesty is essential in research. Uh There's been a number of research uh II brought up rep replication studies. The reason replication studies are important is there's been a number of research. In fact, there was an article I think about 10 years ago, which actually looked at all the uh uh all the papers published in the British Journal of Surgery. And they found that 40% of it was apparently not replicable and that is kind of scary. That means there were 40% of articles which we use as our guide were not actually replicable and did not get the same results. Again, I'm not saying they are not honest, but maybe, I don't know the sample size was inadequate. Maybe the uh environment was very tightly controlled. You remember, a lot of this depends on your inclusion exclusion criteria. If the inclusion criteria is extremely stringent, it becomes such a narrow field of study that you are not able to apply it to a wider range of population. And that's when we run into trouble. So I if I studied purely on acute appendicitis, I now cannot apply that into my chronic appendicitis patients, right? And we sometimes forget that. We think appendicitis is appendicitis. What, what's the big deal? So honesty is very important in that. We have to be very clear. This is what I've done. This is what I found. This is the positive results, this is the negative results. And this was my weaknesses in the study. And if we are not honest with that, we end up taking a lot of people down the wrong road, we end up impacting patient care. So I think you're absolutely right, honesty is something we have to emphasize very clearly. Uh a lot of people, you know, especially when they do long term research and then they find, hm uh my results are not fitting, they do what is called POSTOP analysis. So I started out with the research question, II would do this whole research and I find that my research question is not significant. I dropped that I take the data and I try to, you know, fit as many criteria as possible. I put a against BB, against DC, against B just to see which one gives me ap of less than 0.05. And then I'd say this is my research. That kind of research is not a good quality research because you are not being honest. You did not start off with a uh you know, uh preexistent question and move forward. What you're doing is you're just doing ad hoc post hoc analysis, you're looking back and you're just creating uh data, creating positive findings where there was none. Uh So we have to be honest with ourselves. Are you absolutely right. Do you believe in P less than 0.05? You're asking me very sensitive questions? Uh That is that really, really significant? No, it depends on what you're talking about. Ap less than 0.05 is just a statistical term. We used to make ourselves feel comfortable there enough. Uh People who are enough statisticians by statistics who debunked that idea that P less than 0.05 means I have now found the gold, you know, gold mine and I've struck gold and I've got everything correct. No, it's not p less than 0.05 just tells you that there is a less than zero point. Uh There's less than 5% chance that your study uh results were uh uh were wrong. That's all, that's what it says. So there's a 95% chance that your study results are correct. 5% chance that your study results is wrong, which actually says that there is still a 5% chance that would you do a surgery if there's a 5% chance of mortality? You wouldn't, right. Uh So, so in that same sense, less than 0.05 doesn't mean much. Uh But for want of a better statistical tool at this point in time, a lot of people use P less than 0.05 or less than 0.0. 1, of course, we have moved away. We are looking at things like effect size. We are looking at other things now. So there are different ways of looking at it. Um, but at this point in time for the simplest statistical uh assessments, we do still use the P value. Yeah. How do you choose the right study design for your research then? Ok. So how do you start uh uh how do you choose a correct study design? Mm I guess it depends on uh what is it you want to uh what is it you want to find? The first step is always getting the correct research question. You have to ask the correct question. So uh I think you have to be as specific as possible. You have to be, as I said, feasible. Uh You have to consider the clinical relevance. Uh And once you have got all of that, then you have to decide. Now, I've got this research question. I'm very clear about the research question. How do I implement it? Uh is, would I do a prospective trial if I do a prospective trial for, let's say something like pancreatic cancer? How many years do I have to wait to find the adequate sample? Right. If I do a retrospective study, what about the missing data which might impact my study? Is there more bias if I do a retrospective study? So these are questions you have to ask yourself again. I go back to, this is the time I mentioned the mentor, this is where a mentor uh uh teacher comes in, in, in place. You, if you have somebody who is experienced enough, you can sit down with them and tell them, I want to study the actual impact of pancreatic cancer in my group of patients uh who have got these risk factors. He's going to tell you, look, I've been working for the past 30 years, I've seen probably, I don't know, 50 cancers in the past 30 years or 100 cancers in the past 30 years, you would not be able to find that kind of data. Why don't you look retrospectively? Why don't you look at a different population? So that's when a more senior, more experienced person comes very much handy. And that's what the role of a mentor he's there to kind of nudge you into the correct direction. And yeah, so uh the, the, the study design itself depends very much on your question to as to make it as simple as possible. So how can you ensure your data collection methods are reliable and valid? So, uh the data collection, reliable, valid. Uh First of all, we started earlier with research question, the research question will take you down to the objectives. So you define the objectives based on the research question. Once you've got your objectives, you now uh you now can decide, do I want to do a randomized controlled trial? Do I want to do a double blinded, triple blinded randomized controlled trial? Do I want to do a uh a cohort study? Either prospective or retrospective? Do I want to do a case control study? Uh looking at the risk factors of certain diseases. Once you have decided that you identify the population, the population is important in the sense that you need to be very clear about inclusion exclusion criteria. You make the inclusion exclusion criteria too stringent and it is not applicable to the wider population. You make it too wide and your results are going to be haywire. So you need to find the correct balance in the inclusion exclusion criteria. A lot of people nowadays have moved away from very stringent inclusion criteria primarily because they say it should mimic the real world. The real world is not uh artificial, it's not a patient who is aged between 18 and 45 who is a male. So you know who's got all these risk factors. That's not the real world. The real world is patients as they come, right? And so sometimes the inclusion expression criteria cannot be too stringent even though it helps you in the analysis, uh too stringent is not Generali and then once you have done the population, you have to assess the sample size, sample size is something that scares a lot of up and coming. Uh researchers primarily because they don't understand why is the sample size so important. Why can't I just do this study? The reason a sample size is important is simply because if you do an underpowered under sample size, you know a small sample population and you get a negative result and you publish that negative results, it is going to convey the wrong message, an underpowered under sample size uh study group is not accurate, the results are not gonna be accurate. That's why sample size is important. So you need to define your sample size, you need to calculate it, you need to make sure your data is actually above that minimum number of sample size. Once you yeah, go ahead. Perhaps you can just give us a brief explanation about sample size in the past the sample size. OK? So some people might not be familiar with that term. OK? What is uh sample size? Uh And what is uh what do you mean by power? Uh The sample size is basically the minimum number of patients uh or the minimum number of uh uh data points you're going to be collecting to uh to as a, as a baseline variable. And usually this relates to uh the type of error that you might actually uh you might actually be facing. So when you have got uh a sample size, that is uh uh how should I put it? Mm So when you actually have a uh I'm I'm trying to think of the correct way of putting it. So you, when you have a larger sample size, the power of the study becomes stronger and uh your uh error type two error actually reduces. And that way you do not have the biases. And that's why the sample size is very important. And just to find type two for the audience again. OK. So, uh type two error is basically, uh the type of error which you get when you actually have uh um uh when, when, when, when uh OK, how a type two error is actually uh not rejecting the null hypothesis when it's actually uh false. That's, that's usually how uh uh they, they, they uh define it because you're basically using a type two error not to reject the null hypothesis, which is actually false. And uh but that's not the same as uh accepting a null hypothesis because it's a double negative, right? And uh the hypothesis testing is only used to reject now, hypothesis. So we're going into very um technical terms of uh what type two errors is. And uh it's basically used to hypothesis test and to describe uh the error that happens when we reject another hypothesis. That is false. Does that make sense? So all of this is gonna take time and resources. Yes. Now what I love about the um master's programs, you have research built in to your master's program. Whereas in the UK, research one had to step off a program, find a benevolent mentor, do your research and then step on the program and you may or may not have an income during that time. What's your advice on time and resources? Sorry. So you're asking me, what is my uh advice on time resources or on the fact that uh well, I II really like the fact that at the University of Malaria, your master's program intrinsic in the program is a period of time in research. You're expecting your master's trainees to do research as part of the program. So they salaried unemployed and they're doing research in the UK. By contrast, in doing research, one had to find a benevolent mentor, do your research and that mentor may or may not have research funds or you may or may not have grants. The, the, the main difference is, as I, as I mentioned, uh when I was here in Malaysia, despite the fact that we actually had incorporated research into our master's programs uh in the post graduate training programs. Uh It was always taken by our trainees as a chore. It was something I had to do to be allowed to sit for the final exam. That's how we looked at it. Uh The philosophy behind doing the research was not there as opposed to when I went to UK. Despite the fact that it was not part and parcel of the post graduate training requirements, it was something you did beyond above and beyond your uh your your postgraduate train. Uh It was part of the culture that everybody does research, everybody publishes, everybody presents some sort of detail, everybody does something other. So that that is one significant difference, I guess in that there is already a culture of research, a culture of asking questions, a culture of looking for answers. As opposed to here, we were still, you know, not really uh very much interested in research for the sake of research itself. That said that is changing. Even in Malaysia, it's changing in Asia, it's generally changing. You see so much more people in Asia publishing, what used to be probably 95% of the publications used to come from Europe and us has now changed. China, India, a lot of Asian countries are publishing significant numbers and that's probably because our culture has changed enough for us to start asking the same questions. So in Malaysia, we have been lucky, relatively lucky in the sense that um when we first started this post graduate training programs, we learned from some of the mistakes we've seen in the Western world in UK, especially our, our system is very much based on UK systems. So we learned this and we decided at the beginning this was way before I even went to medical school, probably in the seventies. Uh the the pioneers in the post graduate training decided that research should be an essential part of uh of post graduate training. And that was incorporated in uh though the, the actual environment was not there, that requirement was there and that environment was built over a long period of time. And now we've got an environment where we actively start teaching this postgraduate trainees. From year one, we actually assign research supervisors. We have got a uh an environment where we actually have got classes on how to do research clinics on how to improve your research. We have regular assessment of their research progress and they have to present this research to us prior to sitting for the exams. Uh We have managed to move from a point where probably about 30 to 30% of our research used to be published previously to now close to about 70% of our research is being published. We aim to try to get it as close to 90% as possible because there's no point in doing research if you're not going to share that knowledge with the, the, the, the wider world. And so that is the ultimate aim, you can't do research and keep it in your uh dusty shelves, you have to have it published. So as we come to a close, then what would you recommend, what would be your advice about writing up your research? So how do you write up the research? Um Again, once you've actually got the background information, you've got your research question correct. You got your objectives. Correct. Uh Right. The research becomes easiest. I usually start. So II, I'm just gonna share my personal experience. I start with the research question I start with. Hm. There is something wrong with this particular thing. There's, there is an increase in the infection in the VP shunt infection rates. And I've noticed that this has happened in the past two years. So that's my research question. I would then sit down and look at what is the information already available in the literature. So I'm basically looking at what is already available. Uh What does the literature say about infections? And once I have established the latest literature, I now start looking at what is the uh gap, what is missing? So is it a certain type of prophylactic antibiotic issue? Is it a certain type of infection issue? Is it a instrument issue? Is it a doctor's issue? Is it a surgeon's issue? So that's the gap. And so I II look at what is information available, what is not available? How am I going to find that information? So that's my third question, right? So I've moved from, these are the information I already have available. This is what I'm trying to look for. This is how I'm going to do it. So that's the introduction of methodology written now. Yes, exactly. So you've already, if you follow this, you've already got your three paragraphs written out and that, that moves you to the methodology at this point, we move to the methodology section which is usually the easiest section if you do it properly. So you've already established how you're going to do it. I'm not going to do a retrospective analysis of all my B patients, which means my methodology is uh this study was done in, you know, medical center or from a period of such and such to such and such uh in this wards, the data was collected from this point and this is how I actually assess uh collected. And these are the data I've collected. So that's the methodology I have analyzed this with a uh uh quantitative analysis using T student tests and uh you know, whatever uh analysis methods you have used. And I've looked at the uh factors involved by looking at uh doing a regression analysis or, or, or, or anything else you have done. So that's the methodology that's done. The results results are relatively straightforward. Once you have got your data, you've established, what is it? Remember we have done the objectives. So each objective must be covered in your results. There should usually be one demographic table which tells everybody this is what uh the general population of my study is. And a second one should be the 2nd and 3rd and 4th should answer your objectives, your all your research questions. So objective one should have one table or, or, or, or, or a visualization of some sort. Uh I prefer visualizations to tables because a visualization, a plot or a box plot or a line graph or a histogram conveys more information in a much faster way compared to a table which is very dense with information and numbers. So I prefer those kind of things. You can always give that detailed table as supplementary data. It's better to, you know, we we have a very short attention spans. You don't want to bore your audiences. So you want to give the information as clearly. And in as short, uh you know, as a little information, little words as possible. So that somebody who is looking at it, we are very visual people, especially surgeons. So you look at it, you can actually pick it up. OK? Line A is bigger is greater than line B which means line A is the correct to do. So that that then goes to your discussion, your discussion must reflect what you wrote in your introduction. You have to start back again with what was the problem you were looking at? What is known about the problem, what have you now done with the problem? And what have you find, found out? And based on that you say this is my results and this was what I have found. You must end it with. These were the limitations of my study and I would like to do a future research. Uh you know, looking at these various factors which was not looked at or which were the weakness of my study. That's it. That's the paper. So to write up a paper. Once you have done all of this, it, it just becomes uh uh almost routine, almost, uh you know, uh reflexive, one bit of advice that I had from Mr Christopher Lincoln is a pediatric card at the Brompton Hospital. If you start on research, finish it, you'll find that it's very easy to start and you're collecting information and you're filling the book. But it's like running a marathon. It's the last few miles of the marathon about the hardest because it takes effort and time to polish the language, the diagrams. Yes, written article to get it in a product. That's where many people give up at that point because that's when you don't see much in the way of results or return because it's a hard grind. And in that regard, you should embark upon research that you feel passionate about. And you're interested in Christopher Lincoln said those who do not complete their thesis, it becomes a kiss of death, right? Yes. That also depends as you say on having a good mentor to help you through those last stages to keep an eye on your progress and really to hold you to account, to deliver what you set out to do. And it's not easy. It is difficult, but it's extremely rewarding and it does focus the mind, but also open it up to a lot more in the way of critical thinking. Would you like to ask me any questions? Yes. Uh uh Very much so. I mean, you have been doing, uh, I mean, you have been a surgeon for a long time. You have been working in the UK. Um What was your experience especially? Uh, the thing is I find myself, uh uh what I used to research for now is I II used to start off with clinical research and now I find myself interested in uh a lot of other things. You know, I find myself distracted here and there. How do you keep your focus? How do you build on your uh basic, you know, basic work? How do you keep going on the in the same direction and make a difference? Because I find sometimes drifting off and losing focus. What, what is your advice as a senior colleague every day presents a new question. And I think once you've embarked upon research, every patient, you see every opportunity to see every ward you look at. There's a question, a pertinent question. Why? So we have focused on patient research which can do work on quality research, processing uh human factors, system errors. All these are now current elements that improve the way we work and how we deliver the work. And there's still a lot to be done. If you look at the way hospitals run and the way services are delivered, they're not too dissimilar to what was happening 70 years ago at the beginning of the NHS. Indeed, you can take a doctor back in time and put them in a hospital and they know exactly what is going on. The thing is our systems have not changed. Our hospitals have not changed and we've become conditioned to think because that's the way it's always done around here. I think if we're really going to improve, we have to have a restless discontent for the status quo and think is this good enough? We can always do better and you can think about different ways of measuring, for example, wound infection. I've sat there in meetings where people have said that's not a wound infection, it's slightly red, that's not a wound infection. It's a bit oozy. Turn the question round. Is that a perfect wound? If you start looking at perfect ones and counting that a perfect wound for a patient is low cost and hassle free. So it's the, I think it's the way we think. And if we approach each clinical day in each opportunity with a different mindset will open up a lot more opportunities. The other thing is as we working together, we're no longer working as neurosurgeons and cardiac surgeons or there's so many other people involved in the team and in doing that thinking from their perspective and thinking, interdisciplinary also creates a lot more opportunities for inquiry and research. But is it curious, critical thinking and curiosity and that's what keeps you going all the time. Uh, you, you, uh, you are absolutely right because, um, when we first started and you asked me, what was I interested? I said, uh, you know, this is my research areas and I'm embarking on, I mean, I'm looking at new things because, uh, these new areas keep me alert, uh, they keep me excited, they keep me asking more questions and I find, uh, that is as important as asking clinically relevant questions for my patients. And uh uh it, it, it keeps my mind and I guess that's the uh that's the last message I would like to uh leave our audiences with because uh I don't think of research as uh uh something you have to do as a chore or as an additional burden. It is something that is going to help hone your mind make you uh critical, much more critical, much more curious, much more uh logical person who actually is going to benefit your patient in the long. I mean, it's going to benefit your patient and your patient's care in the long, right? And I uh and I hope uh a lot more of you all will be interested in asking questions, ask as many questions as possible. Ask your, look for people, look for mentors, look for friends, ask questions. And I think that that's the best way to start on research. I did, I did my research in a laboratory and Mike Scully, who is my supervisor said, don't underestimate the power of the line. So change over time and literally, you have a graph in doing that. And what I noticed as an aside, I was doing an experiment where I was sampling cells every four hours and I spent 72 hours in the laboratory sampling. And I consistently got that sort of 56 hours a sort of wobble in the line. All right, didn't make anything of that, but I consistently got that. What was interesting is that people who work in laboratories normally doing experiments 9 to 5 and sampling between nine and five and not sampling overnight. And there, I was having been a a cardiac registrar used to being up all night. I was doing experiments overnight and sampling overnight. And it led me thinking, is there an adherent bias in laboratory work because not people, many people are doing overnight experiments. So maybe from curiosity point of view, we should change the way we think about doing our research. And even the time I'm extremely grateful to van for stimulating us this experience. Thank you for joining the Black Belt Academy this evening. I see I haven't been looking for questions but Gabrielle have any just in the specific I can see there was one from John R about the research, but it's more general. So if, if you want to answer that, um it's about whether our guest has researched nanoparticle hemotherapy as an adjunct to surgical intervention to remove brain tumors. Uh Yeah, it's, it's too strong a question because John, that's very specific. I'll have to ask scientist to and come back to you if I may. Uh That looks really interesting. Thank you very much for joining us. We wish you well, we'll be alive again next week. We'll go back to the technical skill and con continue with the Forceps. So thank you. Good night. Good day and see you next week. Do fill in the feedback forms, please to get your certificate and do if you enjoyed it, tell your friends and right toward.