Research is a process of systematic inquiry that entails the collection of data; documentation of critical information; and analysis and interpretation of that data/information, in accordance with suitable methodologies set by specific professional fields and academic disciplines. For doctors, ‘Biomedical research’ focuses on the prevention and treatment of diseases that cause pain, sickness, and suffering in humans and includes basic, clinical, and epidemiological research.
Myths about biomedical research.
There are several myths about biomedical research including 1. Research is meant for basic scientists & not for us, 2. Research is a waste of time, 3. Research is difficult as it needs funding, a high-tech lab, and a huge infrastructure, 4. Research should be done only in tertiary care centers, which are meant for it. 5. Where is the time for research in my busy practice, 6. Research will impinge on my patient care activities, and 7. Research is a thankless job as it offers no financial benefits.
Three primary duties of a physician.
Our primary duty as clinicians is to treat the ailing and we should do it with the utmost care, knowledge, and expertise. Teaching, formal or in-service, to junior colleagues is essential to pass on the practice of medicine to the next generation and is our second most important duty as clinicians. Research is another essential component of the duty of a practicing doctor. If research is to address questions, doctors are the ones who face questions and are the ones who have the training, expertise, and material to answer them. Research enables doctors to evaluate their practice objectively, advance their discipline, develop new skills, and improve patient care.
Purpose of Research.
Any scientific work needs strong dedication and commitment. The purpose of biomedical research should be to advance knowledge in science and biology, relieve human suffering, and pain, and save human lives. We should encourage projects which answer those problems facing society. Research should define treatment protocols or alter existing ones. Duplication of research done by others is a waste of time and should be discouraged unless published work is under the scanner. We need a high degree of honesty and ethics in planning, conducting, and executing research especially when humans are involved in experiments. Analysis of data should be done with utmost care and honesty and evaluated critically for their value to science and the community. Once published or presented data should be reproducible and should make an impact on science.
Essentials for Biomedical Research.
I believe the following are a must for conducting biomedical research: 1. Acute vision (Eagle eye) to identify hidden secrets of nature or problems which cause human suffering, death & disease; 2. Passion to uncover the truth at costs that are heavy and painful; 3. Aptitude to conduct oneself with ethics, dignity, and respect for the system; 4. Excellence in doing things with innovation & Novelty; 5. Leadership qualities include communication skills, confidence, commitment, and trust in fellow members. In addition, several other factors help in conducting research which includes institutional basis or support; infrastructure & high-tech lab; funding and other financial support; team support and teamwork and family support.
Predatory Publications: A Real threat to Biomedical Research.
Predatory journals/publishers misuse the open access model by demanding huge amounts of money as article processing charges from authors to publish their articles. India has become the hub and one of the topmost predatory publishing countries in the world. Many publishing houses have mushroomed in different states of India in which low-quality papers are accepted without going through a standard peer-reviewing process. Most of such papers are published in subjects related to health & medical sciences (25.48%), and pharmaceutical sciences (24.20%) and are available online free of cost.
Evaluation of Scientific Research.
Evaluation of scientific research has been a matter of great debate over the last several decades and the opinion about it has evolved and is now available to all. What methodology should be employed to evaluate the importance and significance of any published scientific research work in Medicine & Biology comes under several headings.
Invention.
The invention is the highest order of research and refers to creating a new device or tool which has a major impact on medicine & biology and mankind. Such work is done by highly intelligent/distinguished researchers who spend their life on such an invention. The work is usually published in scientific journals like Science and Nature. Classical examples would be the invention of the CT scanner by British inventors Godfrey Hounsfield & James Ambrose and the MRI scanner by Paul Lauterbur & Peter Mansfield.
Discovery
Discovery is the next highest order of research, and this brings to light an agent /disease previously unknown and with a major impact on science & biology. Discoveries again happen when highly dedicated researchers spend their life to explore the unknown. This work finds its place in highly respected journals and makes a major impact on society as well as humanity at large. A classic example is the discovery of hepatitis viruses (A to E) in medicine. The path traversed in the discovery of hepatitis viruses has been a fabulous journey and I was blessed to be onboard for a wonderful trip (Khuroo et al. The Discovery of Hepatitis Viruses: Agents and Disease. J Clin Exp Hepatol. 2020;10(4):391-401).
Breakthrough research work.
Breakthrough research work is the next in importance and is defined as a significant advance or development or progress in knowledge or management which affects a large cohort of the population. This is also accomplished by highly dedicated research workers and finds its place in highly reputed medical journals. Examples of this work usually relate to the use of a drug in common diseases or a surgical procedure for a complicated disease. I have fortu¬nately been involved in 2 research protocols that come under breakthrough scientific works namely the use of proton pump inhibitors in peptic ulcer bleeding and percutane¬ous drainage in liver hydatid cysts and both these works were published in 3 articles in the bible of medicine namely New England Journal of Medicine (1997; 336: 1054-8. 1997; 337:881-7. 1998; 338:391-393).
Level of evidence.
Next in importance is to evaluate research based on the “level of evidence” and this is defined as the strength of evidence obtained from research work regarding a particular practice of medicine or therapy. Level of evidence is the cornerstone for practicing “Evidence-Based-Medicine (EBM)”. EBM has become one of the most important sciences in the practice of medicine in the recent past. EBM evaluates any scientific work from the level of evidence as Level 1 (Scientific papers based on “Meta-Analysis” of Randomized Controlled Trials); Level 2 (single large Randomized Controlled Trial with good randomization and double-blinding); Level 3 (Observational studies include cohort, case-controlled, or cross-sectional studies); Level 4 (Case series or case reports); Level 5 (Personal opinion). Our group has had the distinction of publishing six meta-analyses articles with level 1 evidence [Aliment Pharmacol Ther. 2004;20(9):931-8 & 2005;21(4):347-61; Liver Transpl. 2004;10(9):1099-106; J Gastroenterol Hepatol. 2005;20(1):11-25; J Clin Exp Hepatol. 2014;4(3):226-40; PLoS One. 2015;10(3):e0121450] and several large double-blind randomized trials with Level 2 evidence [N Engl J Med. 1997;337(13):881-7 & 1997;336(15):1054-8; Br J Clin Pharmacol. 1992;33(5):477-85] and numerous large observational studies published in high-ranking international journals (Examples: Lancet 1990;335 (8704):1503-6. & 1995;345 (8956):1025-6).
Journal Impact Factor (JIF).
Only a small percentage of scientific works can be evaluated by the above-mentioned methodologies. The methodology which has received the best attention to evaluate scientific works and can be applied to these globally is “Journal Impact Factor (JIF)”. JIF does not evaluate the scientific work but scores the journal, in which the work has been published. JIF is calculated by dividing the number of current-year citations from the journal by articles published in that journal during the previous two years. JIF of all journals listed in Medline & PubMed is published by Clarivate’s Web of Science. JIF is a very useful guide for librarians and authors to select desirable journals. Recently many institutions have used JIF to evaluate scientists as well because it gives a simple metric. International review committees now take more notice of JIF when they do not have the knowledge to evaluate scientific publications independently. Few journals with a very high JIF where we have published papers include Lancet (202), NEJM (176), Ann Intern Med (51.6), J Hepatology (30.1), Gut (23.1), Gastroenterology (23.7), etc.
Citation index and h-Index.
A citation index is an index of citations between publications and allows researchers to define how often a particular scientific paper is referred to in the literature available either on Web of Science, Scopus, or Google Scholar. The h-index is an author-level metric that measures the publications’ productivity and citation impact. The h-index is calculated by counting the number of publications for which an author has been cited by other authors at least that same number of times. For instance, I have 240 articles with 12405 citations, and 57 articles have received 57 or more citations. So, my h-index is 57. What is a good h-Index? Hirsch reckons that after 20 years of research, an h-index of 20 is good, 40 is outstanding, and 60 is truly exceptional. In his paper, Hirsch shows that successful scientists do, indeed, have high h-indices: 84% of Nobel prize winners in physics, for example, had an h-index of at least 30.
the World’s Top 2% Scientists.
Recently Stanford University has used “the World’s Top 2% scientists” to rank individual researchers. They included over 8.5 million Researchers worldwide in 22 scientific fields, & 176 subfields with the largest group in clinical medicine, and used bibliometric information contained in the Scopus database. A composite citation index (C-score), based on citations with emphasis on single, first, and last authorship with & without self-citations was calculated. Each researcher is given a C-score (with & without self-citations) and based on that ranked amongst all scientists & subjects wise. Based on C-Score, 159,684 researchers were included in 2021 in ‘the 2% Top Scientists’ from the whole group worldwide, in which 1,494 Indian scientists qualified with 2 from SKIMS.
NEJM Journal Watch Citation.
NEJM Journal Watch reviews over 250 scientific and medical journals to present valuable and important clinical research findings and insightful commentary for physicians. Our group holds the distinction of being included in NEJM Journal Watch. Example: Atif Zaman, MD, MPH, reviewing Khuroo MS et al. Aliment Pharmacol Ther 2005 Feb 15. Prophylactic Band Ligation Is Superior to β-Blockers for Preventing Variceal Hemorrhage. NEJM Journal watch. April 12, 2005.
Editorial.
Some articles of major importance in Medicine and biology carry edito¬rials in the same issue of the journal by experts in the same field, which gives an independent report/critical analysis of the work published (usually done by a distinguished expert with similar research background). Two of my articles had accompanying editorials to highlight the importance of the research work. Example: Editorial “Saltzman JR, Zawacki JK. Therapy for Bleeding Peptic Ulcers. New England Journal of Medicine. 1997;336(15):1091-1093” was published with my article “Khuroo MS, et al. A comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med. 1997;336(15):1054-8”.
From the above write-up strengthened by personal examples, it is evident that doctors should do research by asking questions in their day-to-day practice and answering them. Through this, they can explore the unknown, expand knowledge in medicine and biology through discoveries, and breakthrough research work, publish papers in international journals with high impact factors, and get personal recognition through a high citation index and h-index. Such endeavors will relieve human suffering and pain and save millions of human lives for generations to come.
(Khuroo is MD, DM, FRCP (Edin), FACP, Master American College of Physicians (MACP, Emeritus) and former Dean & Director SKIMS and Ex-officio Secretary to Govt.)