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Research Success:Research Success:

A Scientific AutobiographyA Scientific AutobiographyByBy

Kevin M. Means, M.D.Kevin M. Means, M.D.

Undergraduate EducationUndergraduate 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

Medical SchoolMedical 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

PM&R ResidencyPM&R ResidencyRehabilitation Institute of ChicagoRehabilitation 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 don’t?– What conditions favor a positive treatment

response?– What can we do to allow more patients to

improve or benefit?

PM&R ResidencyPM&R ResidencyRehabilitation Institute of ChicagoRehabilitation 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

University of ArkansasUniversity of Arkansasfor Medical Sciences (UAMS)for 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 PM&R– 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

Intriguing Question Stuck With MeIntriguing Question Stuck With Me• Challenging• Needed a solution (practical)• PM&R Literature virtually absent in that area• Found related information (e.g., gait/balance

in stroke) but nothing specifically addressing falls in elderly patients

• PM&R well suited to address this problem – because of neurological and musculoskeletal

impairment issues

• Few in our field interested in that area

Uncharted TerritoryUncharted 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

What Tools Do I Need?What Tools Do I Need?

• I wanted to learn more about this area

• I had some of the clinical tools

• I didn’t 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 PM&R Departments)

Obstacles to ResearchObstacles 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

The EndocrinologistThe 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 PM&R, and I knew nothing about endocrinology

The Endocrinologist (continued)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 couldn’t 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.

My First Research GrantMy 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

My First Research GrantMy 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)

Research TeamResearch 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.

Research TeamResearch Team• Dan the PhD Social Worker

– Had some experience with the research process; worked in the VA

– Knew nothing about PM&R– 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

Research TeamResearch 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

My Second GrantMy 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

Formal TrainingFormal 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• Statistics—Not 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….

Formal TrainingFormal 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

A Big DecisionA 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 Master’s – It would be tough to launch the NIH study and

complete the program

• LEARN research or DO research?

New Mentor – Jerome Tobis, M.DNew Mentor – Jerome Tobis, M.D

• For the NIH FIRST award, I needed a PM&R 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

PM&R Research in NIHPM&R Research in NIH

• In 1992, few physiatrists were funded by NIH as a principal investigator– PM&R had researchers, but NIH was

not our primary funding source

– No PM&R institute in NIH (PM&R research is part of NICHD)

– No PM&R study section in 1992

Gaining MomentumGaining Momentum

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

The Missing PieceThe Missing Piece• I still needed a statistician to help us write

up collected data– Dan didn’t know stats very well and Bob

Harrison had left UAMS

• Statisticians I knew were not that helpful• I eventually met Patricia O’Sullivan, Ed.D.,

who worked for the UAMS College of Nursing

• Pat and I became long-term collaborators, along with Dan Rodell

Know Your CompetitionKnow 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

Know Your CompetitionKnow Your CompetitionKnowing 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

Example: Obstacle CourseExample: 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

Why I Do Research?Why I Do Research?

Research won’t 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

Why I Do Research?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

Are You A Researcher Type?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 mind—I wonder how? If? Why?

• Researchers are quality improvers and strive to make things better

Research and Clinical PracticeResearch and Clinical PracticeComplement Each OtherComplement 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

Researchers Need Time To ThinkResearchers 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

Use Your Time WiselyUse 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 don’t duplicate what they did (don’t repeat their mistakes) but you can improve on what has been done

• Network

The Bottom LineThe Bottom Line

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

You Can Never Know It AllYou Can Never Know It All

The answer to one question leads to more questions