Micro-research: Opening the Innovation Door to Anaesthesiologists and Anaesthesia Nurses in China

Editor—The importance of clinical research is widely recognised, and the number of clinical trials conducted in China is increasing.1Yao C. Clinical trial in China: the status and challenge of data management and statistical analysis.J Evid Based Med. 2018; 11: 3-6Crossref PubMed Scopus (8) Google Scholar As of July 20, 2021, China has launched 21 595 clinical trials, accounting for 5.62% of all trials registered on clinicaltrials.gov. However, taking the 1.41 billion people in China into consideration, which accounts for 20% of the world's population, there is still room for growth of clinical trials in China. We recently conducted a survey to examine the clinical research status of anaesthesiologists and anaesthesia nurses in China. We found that many anaesthesiologists and anaesthesia nurses had misconceptions about clinical research, and conducting clinical research was fraught with numerous challenges for them. To address this dilemma, we proposed a novel concept, ‘micro-research’, to enable them to develop their research ability in daily work. Supported by the Guangdong Association of Anesthesiology, we conducted a survey receiving more than 2000 questionnaires within 1 week, from May 7 to 14, 2021. According to the results of our survey (Table 1), 2023 of the 2065 respondents (98.0%) believed that it was necessary to do clinical research, and 1726 (83.6%) of the respondents had previous experience generating valuable ideas during their daily work. However, only 198 (9.6%) of respondents put their ideas into action. There were multiple reasons given, including insufficient scientific research awareness (79.8%), insufficient data management and statistics personnel (55.2%), no available time (48.3%), and no research funding (17.6%). We found that only clinical trials with large samples and long observation periods were thought to be valuable by many anaesthesiologists and anaesthesia nurses.Table 1Results of the survey questionnaire.VariablesNumber (%)Sex Male840 (40.7) Female1225 (59.3)Type of institution Tertiary hospitals1414 (68.5) Other public hospitals610 (29.5) Private hospitals41 (2.0)Occupation Doctor1296 (62.8) Nurse691 (33.5) Medical technician78 (3.8)Attitude towards clinical research Interested, have a good idea, and have implemented and published academic papers198 (9.6) Interested, have a good idea, but have not implemented776 (37.6) Uninterested448 (21.7) Unnecessary42 (2.0) Have an idea but don't know whether it's a good idea601 (29.1)Purpose of clinical research Need for promotion or graduation1569 (76.0) To solve clinical problems1035 (50.1) To publish papers and gain a sense of accomplishment692 (33.5) Be interested323 (15.6)Do ideas occur occasionally in clinical work? Yes1726 (83.6) No339 (16.4)Sources of clinical innovative ideas Clinical findings1688 (81.7) Inspiration from the literature950 (46.0) Inspiration from a third party800 (38.7) No ideas265 (12.8)Obstacles to putting good ideas into practice Lack of time997 (48.3) Lack of team1119 (54.2) Lack of ability and do not know how to start1647 (79.8) Lack of statistical knowledge1141 (55.2) Lack of funds363 (17.6)If only an idea is needed now, and other work such as article publishing and statistics is solved by a professional team, are you interested in further research? Yes1837 (89.0) No228 (11.0)Age (yr) Under 351027 (49.8) 35–45726 (35.2) 45–55268 (13.0) 55–6540 (1.9) Open table in a new tab To address this dilemma, we proposed a concept ‘micro-research’, to help clinical anaesthesiologists and anaesthesia nurses in China understand clinical research. The concept of micro-research refers to clinical research initiated by medical staff (clinician-initiated research), focusing on the details of clinical work, taking the small scientific problems of medical practice as the research content, and solving daily clinical problems. It is different from the ‘micro-research project’ proposed in 2008, which provided financial support to foster local, outcome-based clinical research to develop solutions for local health problems in developing countries.2MacDonald N.E. Bortolussi R. Pemba S. Kabakyenga J. Tuyisenge L. Supporting research leadership in Africa.Lancet Glob Health. 2016; 4: e362Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar For clinical studies, the main characteristics of micro-research are (the ‘Seven S's’ for short): small clinical problem, significance-oriented, small cost, small sample size, short cycle time, single-centred, and simple to perform (Fig. 1). Although micro-research focuses on small problems, it possesses all the key elements required to qualify as clinical trials, including ethical committee approval, informed patient consent, and clinical trial registration. We have been conducting dozens of micro-research studies to solve clinical problems over the past few years. For instance, we found that nearly 40% of patients manifested halitosis during tracheal intubation, and no effective solution had been reported. The young doctors initiated a simple and interesting randomised clinical trial to help anaesthesiologists improve their perception of halitosis by using a videolaryngoscope for intubation.3Chen C. Hei Z. Xing J. et al.Laryngoscopic techniques modulate anaesthesiologists' perception of halitosis in patients: a randomised controlled trial.Eur J Anaesthesiol. 2019; 36: 918-923Crossref PubMed Scopus (9) Google Scholar The results attracted the attention of international peers and were highly valued in guiding intubation protection for anaesthesiologists amid the COVID-19 pandemic.4Hilbert T. Video laryngoscopy during airway management in COVID-19 patients: practical relevance of a recent EJA Christmas issue article.Eur J Anaesthesiol. 2021; 38: 98-99Crossref PubMed Scopus (3) Google Scholar In addition, when facing the extreme dearth of personal protective equipment against COVID-19, we designed a practical protective sleeve for anaesthesiologists to improve the safety of tracheal intubation.5Chen C. Shen N. Li X. Zhang Q. Hei Z. New device and technique to protect intubation operators against COVID-19.Intensive Care Med. 2020; 46: 1627-1629Crossref PubMed Scopus (10) Google Scholar Moreover, we also reported several exceptional cases6Wu Q. Yang Q. Malignant causes of nasal obstruction.BMJ. 2020; 370: m2251Crossref Scopus (1) Google Scholar and developed many fantastic ideas to resolve other clinical dilemmas encountered daily,7Chen C. Shen N. Ma C. Hei Z. Improvement of glottis visualisation during video laryngoscopy by lifting a floppy epiglottis similarly to direct laryngoscopy with a Miller blade.Anaesth Crit Care Pain Med. 2021; 40: 100871Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 8Chen S. Li X. Liang Y. Li X. Liu D. Should we cut the endotracheal tube to prevent kinking?.J Clin Anesth. 2021; 71: 110224Crossref PubMed Scopus (1) Google Scholar, 9Yao W. Zhu W. Zhang Y. Guan J. A simple method to protect the tracheal cuff during double-lumen endotracheal intubation.J Clin Anesth. 2021; 70: 110163Crossref PubMed Scopus (1) Google Scholar which not only enhanced our work efficiency and promoted the rapid recovery of patients, but also cultivated our scientific research ability and enhanced young doctors' confidence and professional outlook. As of June 2021, most doctors in our department, including residents, medical graduate students, and study physicians, have taken part in micro-research projects and conducted studies to solve clinical problems they have encountered. More than 30 micro-research studies have been published in Western journals, including the British Medical Journal,6Wu Q. Yang Q. Malignant causes of nasal obstruction.BMJ. 2020; 370: m2251Crossref Scopus (1) Google Scholar Intensive Care Medicine,5Chen C. Shen N. Li X. Zhang Q. Hei Z. New device and technique to protect intubation operators against COVID-19.Intensive Care Med. 2020; 46: 1627-1629Crossref PubMed Scopus (10) Google Scholar Clinical Journal of Anaesthesia,8Chen S. Li X. Liang Y. Li X. Liu D. Should we cut the endotracheal tube to prevent kinking?.J Clin Anesth. 2021; 71: 110224Crossref PubMed Scopus (1) Google Scholar,9Yao W. Zhu W. Zhang Y. Guan J. A simple method to protect the tracheal cuff during double-lumen endotracheal intubation.J Clin Anesth. 2021; 70: 110163Crossref PubMed Scopus (1) Google Scholar British Journal of Anaesthesia,10Chen C. Li X. Luo G. Zhou S. Hei Z. Realising the full potential of anaesthesiology to promote enhanced recovery after surgery programmes in China.Br J Anaesth. 2021; 126: e157-e159Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and European Journal of Anaesthesiology.3Chen C. Hei Z. Xing J. et al.Laryngoscopic techniques modulate anaesthesiologists' perception of halitosis in patients: a randomised controlled trial.Eur J Anaesthesiol. 2019; 36: 918-923Crossref PubMed Scopus (9) Google Scholar Moreover, some micro-research projects have progressed to engaging with larger studies and win grants for further research. In addition to misconceptions about clinical research, insufficient instructions on study design, statistical analysis, and writing are barriers to implementing clinical research among young anaesthesiologists in China. We asked outstanding clinical scientists to deliver open online courses to discuss their successful experience on micro-research and inspire the audience's innovative thinking in clinical practice. We also took advantage of the internet as a communications and cooperation platform and established a unified and coordinated team for each micro-research study depending on its needs. The micro-research team might be composed of experienced researchers, anaesthetists, surgeons, nursing staff, statisticians, native writers, etc. from different hospitals and universities to ensure promotion of the study design, literature search, data collection, statistical analysis, article writing, and even patent application. Finally, we leveraged an increasing number of scientific research services, including design consultation, data analysis, and manuscript revision, that can be obtained from technology service companies, which significantly removes barriers to clinical research. The Clinical Research Network (CRN) run by health departments and research funders in the UK has provided a successful research network for trainees,11Darbyshire J. Sitzia J. Cameron D. et al.Extending the clinical research network approach to all of healthcare.Ann Oncol. 2011; 22 (vii36–43)Google Scholar which combined local projects (with ethical approval and other details) with (separate) participation in large national or international studies by recruiting patients. Projects such as the National Audit Projects,12Avidan M.S. Myles P.S. Auditing the national audit projects: impact and implementation.Br J Anaesth. 2018; 121: 107-111Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and the specialist training programmes on the development of awareness of research methods, research readiness including completion of good clinical practice (GCP) training, and finally research experience (commonly through a research network) and research fellowships, have also played an important role in promoting clinical trials in the UK. By comparison, China lacks developed research networks like the CRN in the UK. However, China has adopted a variety of policies and measures to promote development of clinical research in recent years, such as increasing research projects and funds, carrying out clinical research skills training, and conducting large national projects such as national audits that might provide major research opportunities for Chinese anaesthesiologists13Zhou S. Zhu Z. Dai W. et al.National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals.Br J Anaesth. 2021; 127: 56-64Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar,14Sneyd J.R. Cook T.M. Waking the dragon: national audit in China and the benefits of having a NAP.Br J Anaesth. 2021; 127: 2-5Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar and that can benefit more medical personnel, including young anaesthesiologists and anaesthesia nurses. By increasing the number of clinical staff with practical experience in research, we can build a culture in which research is valued and pursued with enthusiasm. Currently, the micro-research project known as the Seven S's has been initiated in several Chinese hospitals and has been efficient in encouraging young anaesthesiologists and anaesthesia nurses to incorporate innovative thinking in their clinical practice. It is essential to note that not all research can be micro-research. Although a great deal of discovery science and early phase research would fit the Seven S's criteria, when it comes to generalisable clinical effectiveness research, we will always need larger multi-centre and, in some cases, international projects. However, for many innovative ideas in the clinic, micro-research with small sample sizes at single centres can be carried out as the basis for larger follow-up and multi-centre clinical studies.15Sneyd J.R. Rigby-Jones A.E. Cross M. et al.First human administration of MR04A3: a novel water-soluble nonbenzodiazepine sedative.Anesthesiology. 2012; 116: 385-395Crossref PubMed Scopus (16) Google Scholar These are not mutually exclusive, but complementary. As the largest developing country with a huge resource of patients, China has an important role in medical research and development worldwide. We believe that the concept of micro-research can open the door to innovation for young frontline anaesthesiologists and anaesthesia nurses, and promote development of solution-based clinical research in China and around the world. We thank Qintai Yang and Shaoli Zhou from the Third Affiliated Hospital of Sun Yat-sen University for careful assessment and professional suggestions on this manuscript. We thank Yunshui Peng from the Editorial department of the Chinese Journal of Anesthesiology for constructive suggestions on the concept of micro-research. We also thank Weifeng Tu from the Shenzhen Hezheng Hospital for professional suggestions on the survey. Actually, this work was partly supported by the Fundamental Research Funds for the Central Universities (Grant No. 2021qntd34). The authors declare that they have no conflicts of interest.