Publication

Publication in a refereed journal carries with it the challenges of going through the manuscript acceptance process. Your article will undergo peer review by a number of persons specifically selected for that purpose (usually experts in that particular field). This level of scrutiny can be disheartening depending on how well you handle critique (rarely is a submission accepted without revision), but it is also highly productive as you receive expert sug gestions on improving your article. The process can take a considerable period of time depending on the publisher selected, although most have developed rapid turnaround systems.

Your article does not actually have to be published for your 4.10 to be considered satisfied for the purpose of being eligible to sit the fellowship exam. Evidence of acceptance for publication is sufficient, leaving you free to concentrate on preparing for the exam itself while you wait to see your name immortalised in print.

The strength of choosing publication is that you will have this forever on your CV. Should you choose to continue to publish, the lessons you learn from this experience will be invaluable. Subsequent projects will become progressively easier.

Oral presentation

The most popular form chosen is for oral presentation at a recognised meeting — usually a national, state or regional emergency medicine meeting. This popularity probably arises from familiarity, as this is the most common form of presentation at meetings in general and is similar to the way the majority of teaching sessions are run.

However, even though an oral presentation does not require submission to a publisher, you do need to submit your project details to the College for consideration. When assessing your project, the College follows the same basic procedure as the publishing review process.

The oral presentation tests your capacity to speak in a public forum, keep to time and handle questions asked by FACEM adjudicators. Many of these questions will be the same as those posed by the publishing review process, but time constraints will mean the depth of questioning and time for your response will be much less than via the publishing process.

If you are comfortable with public speaking and have prepared and know your project well, you will find an oral presentation far less stressful. The particular advantage is that the decision to accept/reject your proposal will be made in a known time frame without the uncertainty associated with publication time lines.

Poster presentation

Poster presentations are often overlooked as a format, although they have become increasingly popular in recent years and we encourage you to consider this option. Preparation is essentially identical to that for an oral presentation, including material that must be submitted to the College. However, there is a greater capacity to accommodate poster presentations than oral presentations from the point of view of meeting organisers and so a submission to present a poster (or tick the box that says ‘either’) is more likely to be accepted than a request only to present orally.

Posters do not have to be large, glossy and expensive. Although most posters are professionally printed, it is perfectly acceptable to print out A4 or A3 sheets of paper and arrange them on the posterboard using the standard headings. If you do elect to have your poster printed professionally, allow sufficient time so that proofs can be read and corrected if necessary.

The poster itself will do some of the ‘talking’ for you, becoming a focal point of discussion. Posters are generally put on display for a period of time prior to the presentation session, providing you with the opportunity to get feedback from those browsing by. Explaining your project and discussing issues with strangers in an informal manner is a reasonably low-stress way of finetuning your presentation prior to the session with the adjudicators. Your time with the adjudicators will be split between you explaining your project and them questioning you on details about it. More information can be found on the College website.

A poster also gives you something to take away once you have been successful. The poster can adorn your office or take pride of place in the department for many years to come.

Thesis

If the research bug is part of your make-up, you may wish to commence more formal study from the outset and have the 4.10 project become part of a wider research endeavour. This will require a nominated supervisor and considerable time in planning the way forward. If this is for you, you are strongly encouraged to meet your local or regional research group, who will be invaluable in assisting you with the 4.10 project and your wider research endeavours.

Individual or team

Decide from the outset whether you work better by yourself or with one or more colleagues. If there are a number of you at the same stage of training, you may wish to work collaboratively on several projects, with one of you acting as lead investigator (and author) for each project. Sharing the workload and addressing the issues that arise as a group can be helpful. If you do work with others, however, choose very carefully: you want to work with people who are experienced and compatible and who will pull their weight.

Selecting the topic

Probably the hardest decision you will have to make is what your research topic will be. Sometimes a rush of enthusiasm based on the fortuitous discovery of an interesting research question or dilemma triggers your thinking. However, most trainees need time to select their topic.

Coming up with a great idea will be less of a stumbling block if you have an enquiring bent towards clinical medicine. Why do we choose a particular investigation or way of managing a patient? Is there a better way of doing a procedure? Can we better predict which patients will present or benefit most? These are questions that need to be posed frequently for you to become a more informed evidence-based clinician. Constant enquiry helps in ‘currency’ of knowledge and, in this instance, allows you to formulate worthwhile research questions of clinical relevance and importance to emergency medicine practice.

A research question that captures and maintains your enthusiasm and interest is the start to the 4.10 ‘journey’. This may occur from acute personal observation in your clinical life, attendance at critical appraisal forums, reading the medical literature widely or talking to your peers or consultants about their research interests.

Being forced to think up a project as a deadline looms may be counterproductive if you have not been involved in research previously. This strategic phase of looking out for, formulating and then designing a feasible and useful study may take some time. A ‘shopping’ type approach in looking around to buy the most attractive product is recommended, rather than thoughtlessly committing to the first project offered to you for which you do not feel a deep attachment.

When deciding on a topic, there are three things to bear in mind:

Once you have selected a topic, conduct a literature review to ensure that the answer to your question is not already available. A well-conducted literature review (see Chapter 9) may also provide other research ideas, suggest ways of streamlining your project and give valuable insight into the particular design that will best suit the topic. Because of the time frame involved from start to finish, you should repeat the literature review prior to final presentation, in order to ensure that other relevant information has not come to light during this interval.

Study design

Chapter 9 will provide useful suggestions on different types of study designs. It is unlikely that your first research project will be a multi-centre, randomised controlled trial assessing a major health issue. You will need to develop a balance between higher levels of evidence, which require higher levels of expertise and time, and lower levels of evidence where simpler designs are appropriate.

As a general guide, studies that enrol patients for intervention or observation prospectively are viewed more favourably. However, they can be the most difficult to implement successfully, as proposals must be approved first by ethics committees, medications or interventions may need to be specially prepared in order to ensure adequate blinding and projects that involve follow-up will always involve a percentage of subjects that will be ‘lost’.

Non-randomised studies are definitely inferior for assessing the effect of a medical intervention. Prospective observational studies are useful to detect adverse effects of treatment or to follow the natural history of a disease. On the good news side, nonintervention and non-prospective studies are an appropriate and valid trial design for most other purposes. Although such designs are often mistakenly adjudged to be inferior to the randomised controlled trial, non-randomised designs using easily collected or existing data such as that from cross-sectional surveys, clinical notes, ED patient clinical databases (EDIS, for example), registry information (major trauma registries), mission reports (aero medical service providers) and procedural databases are a valid, and often the only, way to answer non-intervention questions.

For instance, trauma epidemiology is best examined using trauma registries. Casecontrol studies are used to determine the role of detrimental lifestyle factors such as smoking in disease causation. Case series may offer speculative evidence of new side effects of a treatment. Observational series can assess the effects of interventions that it would be unethical to deny to a treatment arm in a randomised trial (e.g. evacuation of an EDH). The critical element in study design is that the study type chosen is valid for, and best suited to, the research question.

The design and conduct of a study is similar to critically appraising a research paper, but done in reverse (for more detail, see Chapter 9). A study needs to be methodologically internally valid before even considering its generalisabilty or applicability. Time taken in meticulous study design is well worth it, as mistakes in design are not easily rectified during the study and may invalidate the study results.

Write your study hypothesis and methods before you commence the study. Ensure that the aim of the study is clear and will be addressed by the methods chosen. The typical headings to consider when writing the protocol for your randomised interventional study are provided in Table 8.1. These can also be applied to other study types, although some sections (e.g. interventions) may not be required or be appropriate. These items also form the basis of submissions to ethics and regulatory bodies. Time spent considering each of these items and how they apply to your project will make such submissions and your subsequent project write-up much easier.

TABLE 8.1 A template for a randomised controlled trial protocol

Statistical analysis

Issues regarding sample size, comparison between groups and specific method(s) to analyse difference will vary depending on the topic chosen and study methodology. Some of these issues are addressed in more detail in Chapter 9. Expert statistical advice is required early in your project to ensure that each method chosen is appropriate and your project is achievable.

Publication

A feature of the publication pathway is that you do not have to present in person ‘on the day’. However, before submitting your paper, you should show it to colleagues with research experience to ensure that your presentation is the best it can be on its first submission.

Do not expect your paper to be approved on first submission: most papers require some revision after the peer-review process. The reviewers will provide con structive critique that will help improve your paper. Do not take these comments personally. Consider each point in turn and ensure that all are adequately addressed before resubmitting the paper. If all issues are dealt with appropriately, it is highly likely you will succeed.

The marking scheme for published papers is detailed on the College website.

Conference presentations and poster sessions

Conferences must be approved in advance by ACEM and adjudication is provided by FACEMs approved by the College. The same principles of preparation apply as for the clinical components of the examination. Your oral presentation or poster session should be well rehearsed in front of peers. These practice presentations are a good opportunity to find out which questions are ‘naturally’ generated by your project. It may not be necessary to change your presentation to include an answer to a question if the point is not crucial. In fact, having been asked a question beforehand about a particular issue or detail and having had time to consider your response may be to your advantage on the day!

Ensure that you arrive well ahead of time, including travel considerations if required, and are familiar with the venue and audiovisual arrangements. Your electronic presentation or poster will be required by the conference management ahead of time. Check carefully that everything ‘works’.

The timing for your presentation will be strictly regulated. You should be well practised to finish with time for questions afterwards. If you run overtime, you will be stopped. Questions may come from the audience in general or, more likely, be dominated by those from the adjudicators. The adjudicators will be particularly interested in your study design, statistical methods, confounders and so on, as their focus is on the process of the project more than simply the results, whereas the general audience is often focused only on the clinical implications. Remember, it is the adjudicators, not general audience, who mark you, so keep this in mind when briefing/choosing your ‘test’ audiences.

Regardless of your mode of delivery, three adjudicators will mark you. Adjudicators are preselected to ensure that they do not have a conflict of interest with your project. One acts as the designated lead adjudicator, and each marks you independently against specified criteria detailed on the College website. At the end of the session, they meet. If all three mark you as a pass, or if two (including the lead) mark you as a pass, you will be notified on the day that you are successful. However, you may still pass if you do not fulfil these requirements, as all papers are referred to the Board of Censors for a final decision.

Once you have completed regulation 4.10, your future publishing and presenting activities will become exponentially easier.