How to improve surgical research

On 15 June the Royal College of Surgeons published its report From Theory to Theatre: Overcoming Barriers to Innovation in Surgery,1 which outlined the problems that surgical research faces and how they might be solved. Surgery has advanced spectacularly in the past 50 years, but many advances have not come from carefully planned research using valid study designs. Consequently, neither the public nor the surgical community seems convinced that we need scientific research into surgery, as opposed to research into diseases that surgeons can treat. That this perception is dangerously wrong is one of the key messages of the college’s report.

The report highlights past surgical achievements to a degree that might lead the naive observer to ask why—if surgeons are doing so well—they need to change anything. However, it also cites the decline of academic surgery in universities, the disappearance of meaningful contact with research from surgical training programmes, and the enormous practical difficulties caused by past failure to build a robust research infrastructure or an intellectual support network within surgery. The most telling fact in the document is that although the Medical Research Council and National Institute for Health Research spent £1.53bn (€1.71bn; $2.45bn) in 2008-9 on research, only £25.5m went to surgical research. This is not a uniquely British problem—figures on National Institutes of Health support in the United States are only slightly better2—but it is shocking considering the contribution of surgery to effective treatment.

The report is honest about how the social culture of surgeons has contributed to this failure. Their implicit model of professionalism makes surgeons reluctant to randomise or to cooperate in large groups—a toxic mix of attitudes that has proved near lethal in a modern research world where single pioneers can rarely hope to succeed. A substantial part of the report deals with the difficulties of implementation once a new technique is shown to be superior, although this is really a distinct (and equally important) problem that needs its own strategy. Setting it to one side might have allowed more in depth consideration of the problems of supporting research itself. The authors identify the lack of incentives and of training opportunities as two of the main reasons for such failures of dissemination. It is always easier to describe problems than to solve them, and current financial difficulties exacerbate this problem by inhibiting ideas that require new funding. Nevertheless, some of the authors’ recommendations will inevitably cost money. They will also require several disparate stakeholders to be convinced by the college’s message. Eight of the 15 recommendations require action by the Department of Health or by NHS senior management via the commissioning and regulatory infrastructures, whereas four will need movement from the Postgraduate Medical Education and Training Board and perhaps the General Medical Council. Getting major research funders to treat surgical research as a special case (recommendation 9) may well be the hardest trick, but one of the most important. The report recognises that many of the crucial levers for helping surgical research are to do with changing the environment within which it exists. There are excellent suggestions about possible incentives for surgeons and trusts. For example, appropriate recognition of research activity by schools of surgery, consultant appointment panels, and clinical excellence award boards would improve motivation within the profession, while the commissioning apparatus could reward trusts that support research via the commissioning for quality and innovation framework and through more rigorous requirements around audit.

The need to reintroduce research methodology to specialist training programmes is recognised, and, importantly, the report identifies a key structural barrier to the adoption of new techniques by calling for specific financial support mechanisms for mentoring and training consultants who wish to start using them. The NHS has never recognised the need for this, but in an increasingly risk averse environment it has become a major problem for surgeons who wish to develop their practice.

Much lobbying will be needed if the report is to achieve its aims. The problems may need to be outlined in starker terms to convince some key players of the need for action, and a compelling vision of the potential benefits of better quality surgical research needs to be presented. The harsh fact is that surgical research desperately needs help to improve its infrastructure and achievements. The report recognises that surgery faces special challenges in designing, conducting, and reporting research, but that an intellectual framework for this is now available.3

A national plan for building the infrastructure needs to be developed, including the development of surgical trials units specifically dedicated to developing and supporting high quality studies of surgical techniques, using appropriate methodology. Attitudes of course need to change: it has always been a puzzle that engineering research, for example, can be intensely practical and results oriented yet retain intellectual respectability, but that research into surgical techniques has sometimes been regarded by academics with disdain. However, a thriving surgical research enterprise that demonstrably benefits patients and society would soon earn respect.