Liaison Faculty09 - Research for NHS Clinicians [Workshop]

Research for NHS
Clinicians
What is Possible?

Alex Mitchell, Consultant in Liaison Psychiatry

Contents
Contents

• Part I: Getting Published

• Part II: Being Measured

• Part III: Real World Outputs from Liaison Psychiatry

Part I: Getting Published
Part I: Getting Published
Why Publish?
Three Bottlenecks
Successes

Your Research

The fate of medical research (DeBakey, 1974)

NHS Power -2004 Stats
Academics
• 494 clinical lecturers (down 17% on 2003)
• 1500 Readers / SnR Lecturers (down 11% on 2000)
• 1146 Professors (up 10% on 2000)

• 3113 FTE clinical academics in all specialties

• 302 SnR academics in Psychiatry
• 40 lecturers in Psychiatry

Academics
• 494 clinical lecturers (down 17% on 2003)
• 1500 Readers / SnR Lecturers (down 11% on 2000)
• 1146 Professors (up 10% on 2000)
• 302 SnR academics in Psychiatry
• 40 lecturers in Psychiatry
• 3113 FTE clinical academics in all specialties
NHS Staff
• 117,000 NHS doctors (up 5% on 2000)
• 34,000 GPs (up 2%)
• 30,600 Consultants (up 5%)
• 397,000 Nurses (up 2.5%)
• 129,000 Allied health professionals (up 4%)
• 1,071,462 FTE qualified staff
• 3,500 NHS Consultant Psychiatrists vs 350 academic psychiatrists

Ca
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e

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Source: DOH Workforce Stats

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Consultants by Specialty

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Source: DOH Workforce Stats

Productivity
Productivity
• Academics
– 3000 x 5 papers per year
– N= 15,000

• NHS Medical Staff
– 120,000 x 1 paper every 5 years!
– N= 24,000

• NHS AHP
– 500,000 x 1 paper every 100 years
– N= 5,000

• Ratio of Outputs = 15,000 to 29,000 (1:2)

Bottleneck 1: Journals
Bottleneck 1: Journals

=> BMJ

Typical Journal Statistics (eg BMJ)
Typical Journal Statistics (eg BMJ)
• 7000 research papers received
• 1000 rejected by one editor immediately
– further 4500 rejected by editors after reading

– Only 25% (1500) sent to reviewers

– Only 10% reach weekly manuscript meeting
• (with Editor, a clinicians and a statistician)

– 350 research articles after revisions (and up to 6 peer reviews)

• Only 3% (1990-2000) to 6% (2000+) accepted by BMJ
=> time!

Conventional Publication Cycle – 24mo
Conventional Publication Cycle – 24mo
T0 T+1mo T+3mo T+6mo
Step1 Step 2 Step 3 Step 4
Paper Present to Present at Submit to
Completed colleagues conference journal
(informal PR)

T+7mo T+10mo T+12mo T+14mo

Step 5 Step 6 Step 7 Step 8
Editor Agrees to Peer Revision 1 Peer
Send for Review Review 2
Review 1

T+15mo T+18mo T+24mo
Step 12
Step 9 Step 10 Step 11
Readers letters
Revision 2 Proof Restricted
(public PR)
Publication

First received 26 Sep 2007, final revision 30 Sep 2008, accepted 20 Nov 2008; 540 days

Open Access Publishing
Discussion Forum (Pub. Stage 1) + Journal (Pub. Stage 2)

Open Publication Cycle – 12mo
Open Publication Cycle – 12mo
T0 T+1mo T+3mo T+5mo
Step1 Step 2 Step 3 Step 4
Paper Present to Present at Submit to
Completed colleagues conference online journal
(informal PR)

T+6mo T+7mo T+9mo
Step 6 Public
Step 5 Step 8
comments
Editor Publishes Revision
Step 7 Peer
“discussion paper”
Review 1

T+11mo T+12mo
Step 11
Step 9 Step 10
Readers letters
Online proof Open Access Publication
(post-publication)
=> Good news2

How Many?
How Many?
• Hospital Specialist

• 75 journals in psychiatry
• + 50 in neurology
• + 50 in medicine
• + 25 in misc. fields

– 2400 issues per year
– 24,000 specialty articles per year

– 6.5 journals per day

– 65 articles per day

The Publishing Landscape
The Publishing Landscape
Example Scope Direct Readership
Generalist titles The Lancet Generalist, very high impact Generalist
(IF5+), closely peer reviewed 1000,000s?
Specialty titles BJPsych Covering specialty as whole, Specialists (mainly
high impact (IF3+) secondary care)
10,000s-00,000s
Sub-specialty J of ECT Specific disease area/therapy Sub-specialists on
titles class, low impact disease
1000s

Primary care PCP Primary care focus, can be low 1000s
titles scientific impact if jnl is new
Magazine titles Pulse Not generally peer-reviewed 10,000s+
but highly targetted readership

Internal titles Newsletter Not peer-reviewed, not widely 100s+
read, never cites

Some Obscure Psychiatry Titles
Some Obscure Psychiatry Titles
1.691 WORLD J BIOL PSYCHIATRY
1.505 NEUROCASE
1.441 PSYCHOPATHOLOGY
1.264 AGING MENT HEALTH
1.229 SUBST USE MISUSE
1.206 ACTA NEUROPSYCHIATRY
1.181 PSYCHIATRY CLINICAL NEUROSCIENCE
1.176 JOURNAL OF ECT
1.062 PERSPECT PSYCHIATR CARE
1.051 NEUROPSYCHIATRIE
1 BEHAVIORAL MEDICINE
0.951 J PSYCHOSOMATIC OBST & GYN
0.752 NORDIC J PSYCHIAT
0.734 ARCH PSYCHIAT NURS
0.733 INT JJOURNAL PSYCHIATRY IN MEDICINE
0.721 STRESS AND HEALTH

Bottleneck 2: Your Colleagues
Bottleneck 2: Your Colleagues

Overview of Peer Review
Overview of Peer Review

Author Filter Editorial Filter Peer Review Filter Outcome

Quantitative
Grade

Grading Published
Accept
Where to Article
Article
Submit Appraisal
Revise
Comments to
Reject
Reject Author
Send
elsewhere
Qualitative
Grade

Bias from Hidden Reviewers
Bias from Hidden Reviewers
Friend
Enemy

Unknown + -

Revision
Acceptance
+ Author
Author

-
Enemy -

Rejection
Unknown

See Maddox J. Conflicts of interest declared [news]. Nature 1992; 360: 205;
Locke S. Fraud in medicine [editorial]. Br Med J 1988; 296: 376–7.

What Makes a Good Reviewer?
What Makes a Good Reviewer?
• A reviewer was less than 40 years old

• From a top academic institution

• Well known to the editor choosing the reviewer

• Author blinded to the identity of the manuscript's authors

• Then the probability of good review was 87% vs 7%

Evans AT, McNutt RA, Fletcher SW, Fletcher RH. The characteristics of peer reviewers who produce good-quality
reviews. J Gen Intern Med. 1993 Aug;8(8):422-8

Open & Blind Review & Submission
Open & Blind Review & Submission

• Does revealing reviewers’ identity influence outcome?
– Open vs blind peer review

• Does revealing Authors’ identity influence outcome?
– Open vs blind submission

• http://www.slideshare.net/ajmitchell

Bottleneck 3: Yourself
Bottleneck 3: Yourself

Problems with Authors
Problems with Authors
• Multiple publication

• Ghost authorship

• Gift authorship

• Conflicts of Interest

• Fraud / Plagarism

Ghost Authorship
Ghost Authorship
• An Inquiry by the UK House of Commons Health Select
Committee into the Influence of the Pharmaceutical
Industry October 2004
– 50% of therapeutics articles may be ghost written

• Flanagin A et al (1998) Prevalence of Articles With
Honorary Authors and Ghost Authors in Peer-Reviewed
Medical Journals JAMA 280:222-224
• Of 809 articles
– 19% had evidence of honorary (gift) authors
– 11% had evidence of ghost authors
– 2% had evidence of both

How Many Authors?
How Many Authors?
• Deep Impact: Observations from a Worldwide Earth-Based Campaign
K. J. Meech, N. Ageorges, M. F. A'Hearn, C. Arpigny, A. Ates, J. Aycock, S. Bagnulo, J. Bailey, R. Barber,
L. Barrera, R. Barrena, J. M. Bauer, M. J. S. Belton, F. Bensch, B. Bhattacharya, N. Biver, G. Blake, D.
Bockelée-Morvan, H. Boehnhardt, B. P. Bonev, T. Bonev, M. W. Buie, M. G. Burton, H. M. Butner, R.
Cabanac, R. Campbell, H. Campins, M. T. Capria, T. Carroll, F. Chaffee, S. B. Charnley, R. Cleis, A.
Coates, A. Cochran, P. Colom, A. Conrad, I. M. Coulson, J. Crovisier, J. deBuizer, R. Dekany, J. de
Léon, N. Dello Russo, A. Delsanti, M. DiSanti, J. Drummond, L. Dundon, P. B. Etzel, T. L. Farnham, P.
Feldman, Y. R. Fernández, M. D. Filipovic, S. Fisher, A. Fitzsimmons, D. Fong, R. Fugate, H. Fujiwara,
T. Fujiyoshi, R. Furusho, T. Fuse, E. Gibb, O. Groussin, S. Gulkis, M. Gurwell, E. Hadamcik, O.
Hainaut, D. Harker, D. Harrington, M. Harwit, S. Hasegawa, C. W. Hergenrother, P. Hirst, K. Hodapp,
M. Honda, E. S. Howell, D. Hutsemékers, D. Iono, W.-H. Ip, W. Jackson, E. Jehin, Z. J. Jiang, G. H.
Jones, P. A. Jones, T. Kadono, U. W. Kamath, H. U. Käufl, T. Kasuga, H. Kawakita, M. S. Kelley, F.
Kerber, M. Kidger, D. Kinoshita, M. Knight, L. Lara, S. M. Larson, S. Lederer, C.-F. Lee, A. C.
Levasseur-Regourd, J. Y. Li, Q.-S. Li, J. Licandro, Z.-Y. Lin, C. M. Lisse, G. LoCurto, A. J. Lovell, S. C.
Lowry, J. Lyke, D. Lynch, J. Ma, K. Magee-Sauer, G. Maheswar, J. Manfroid, O. Marco, P. Martin, G.
Melnick, S. Miller, T. Miyata, G. H. Moriarty-Schieven, N. Moskovitz, B. E. A. Mueller, M. J. Mumma,
S. Muneer, D. A. Neufeld, T. Ootsubo, D. Osip, S. K. Pandea, E. Pantin, R. Paterno-Mahler, B. Patten, B.
E. Penprase, A. Peck, G. Petitas, N. Pinilla-Alonso, J. Pittichova, E. Pompei, T. P. Prabhu, C. Qi, R. Rao,
H. Rauer, H. Reitsema, S. D. Rodgers, P. Rodriguez, R. Ruane, G. Ruch, W. Rujopakarn, D. K. Sahu, S.
Sako, I. Sakon, N. Samarasinha, J. M. Sarkissian, I. Saviane, M. Schirmer, P. Schultz, R. Schulz, P.
Seitzer, T. Sekiguchi, F. Selman, M. Serra-Ricart, R. Sharp, R. L. Snell, C. Snodgrass, T. Stallard, G.
Stecklein, C. Sterken, J. A. Stüwe, S. Sugita, M. Sumner, N. Suntzeff, R. Swaters, S. Takakuwa, N.
Takato, J. Thomas-Osip, E. Thompson, A. T. Tokunaga, G. P. Tozzi, H. Tran, M. Troy, C. Trujillo, J.
Van Cleve, R. Vasundhara, R. Vazquez, F. Vilas, G. Villanueva, K. von Braun, P. Vora, R. J. Wainscoat,
K. Walsh, J. Watanabe, H. A. Weaver, W. Weaver, M. Weiler, P. R. Weissman, W. F. Welsh, D. Wilner,
S. Wolk, M. Womack, D. Wooden, L. M. Woodney, C. Woodward, Z.-Y. Wu, J.-H. Wu, T. Yamashita,
B. Yang, Y.-B. Yang, S. Yokogawa, A. C. Zook, A. Zauderer, X. Zhao, X. Zhou, and J.-M. Zucconi
Science 14 October 2005: 265-269.

Part II: Being Measured
Part II: Being Measured
Impact Factors
Journals vs papers vs
individuals
H-Index
Dissemination

How to Grade Research…of an Author

10% top 10 journals

100% Listed on Pubmed

70% peer reviewed journals

75% Listed on Pubmed
90% Listed on Scopus/WoK

20% other material (eg chapters)

5% Listed on Pubmed
15% Listed on Scopus/WoK


10% top 10 journals
Impact
(citations)

70% peer reviewed journals

20% other material

PubMed Hits for March 2005 (millions)
PubMed Hits for March 2005 (millions)

The Dreaded “Impact Factor”
The Dreaded “Impact Factor”
Q. How do you know what published research is important?
Q. How do you decide what research to read?

What is the Impact factor?
What is the Impact factor?
• Journal IF
• A = citations in the last 2 years in journal
• B = number of articles Impact Factor = A/B

• Article IF
• A = Total citations of article
• B = Age of article Impact Factor = A/B

• Personal IF
• A = citations in the last 2 years by individual
• B = number of articles Impact Factor = A/B

Eugene Garfield
Eugene Garfield

• Citation Databases
– Science citation index (CD)
– BIDS
– ISI Science Direct
– Web of Science
– Web of Knowledge
– Scopus

Medical Journals Impact Factors
Medical Journals Impact Factors

Credit: Panayiota Polydoratou and Martin Moyle

One Journal’s Impact Factor Trend
3

2.5
CMAJ 's impact factor

2

1.5

1

0.5

0
1988 1990 1993 1994 1995 1996 1997 1998 1999 2000 2001

Hoey J, Todkill AM. CMAJ 2003;168:287-8 [online appendix]

Increase in Scientific Output

http://www.americanscientist.org/my_amsci/restricted.aspx?act=pdf&id=3263000957901

Type of Article and Impact
Type of Article and Impact

Good Paper

Importance of Reviews
Importance of Reviews
• WHITTINGTON, C. J., KENDALL,T., FONAGY, P., COTTRELL, D.,
COTGROVE, A. & BODDINGTON, E. (2004) Selective serotonin reuptake
inhibitors in childhood depression: systematic review of published versus
unpublished data. Lancet, 363, 1341-1345.

• Lancet Paper of the Year 2004

• BACKGROUND: Questions concerning the safety of selective serotonin reuptake inhibitors (SSRIs) in the treatment of
depression in children led us to compare and contrast published and unpublished data on the risks and benefits of these
drugs. METHODS: We did a meta-analysis of data from randomised controlled trials that evaluated an SSRI versus
placebo in participants aged 5-18 years and that were published in a peer-reviewed journal or were unpublished and
included in a review by the Committee on Safety of Medicines. The following outcomes were included: remission,
response to treatment, depressive symptom scores, serious adverse events, suicide-related behaviours, and
discontinuation of treatment because of adverse events. FINDINGS: Data for two published trials suggest that fluoxetine
has a favourable risk-benefit profile, and unpublished data lend support to this finding. Published results from one trial
of paroxetine and two trials of sertraline suggest equivocal or weak positive risk-benefit profiles. However, in both
cases, addition of unpublished data indicates that risks outweigh benefits. Data from unpublished trials of citalopram and
venlafaxine show unfavourable risk-benefit profiles. INTERPRETATION: Published data suggest a favourable risk-
benefit profile for some SSRIs; however, addition of unpublished data indicates that risks could outweigh benefits of
these drugs (except fluoxetine) to treat depression in children and young people. Clinical guideline development and
clinical decisions about treatment are largely dependent on an evidence base published in peer-reviewed journals. Non-
publication of trials, for whatever reason, or the omission of important data from published trials, can lead to erroneous
recommendations for treatment. Greater openness and transparency with respect to all intervention studies is needed.

IF Psychiatry Journals
IF Psychiatry Journals

Part III: Real World Research Outputs
Part III: Real World Research Outputs
Journal outputs
Top 10 Psychiatric papers
Top 10 Authors

Journal Outputs
Journal Outputs
Q. What is the effect of a high IF on individual authors?

IF and Submission Ratio
IF and Submission Ratio

• The IF can be considered inversely proportional to the
chances of acceptance

BMJ Manuscript Processing

1000 Hand written
6000 received
Immediately Silly mistakes
per year rejected Wrong journal

2500 Poorly written
5000 scanned by Rejected by Obvious flaws
1 editor editor Too Obscure

1000 Rejected Methodological
2500 sent
by reviewer / concerns
for review editor Not interesting

400 rejected 100 accepted
500
discussed

1500 sent to 400 rejected 100 accepted
500
hanging discussed
committees
400 rejected 100 accepted
500
discussed

300 accepted per year
Acceptance Rate
= 1 in 20 (6 per week + 2 short
reports)

Liaison Journals
Liaison Journals

Impact Factor Abbreviated Journal Title Total Cites Impact Factor Articles Cited Half Life

2.199 PSYCHOSOMATICS 2259 2.199 80 7.5

2.117 GEN HOSP PSYCHIAT 1952 2.117 83 7

2.095 EPILEPSY BEHAV 1937 2.095 178 3.3

2.053 J NEUROPSYCH CLIN N 2396 2.053 55 7.8

1.859 J PSYCHOSOM RES 6203 1.859 157 7.9

1.206 ACTA NEUROPSYCHIATR 201 1.206 45 3.4

1 BEHAV MED 479 1 13 9.2

0.733 INT J PSYCHIAT MED 823 0.733 30 >10.0

Individual Papers
Individual Papers
Q. What are the “most important” papers in psychiatry?
Q. How many times do you think the top papers are cited?

Top 10 Cited Papers in Psychiatry
Top 10 Cited Papers in Psychiatry

Top 10 Cited Papers in Psychiatry_Year
Top 10 Cited Papers in Psychiatry_Year

Top Non-Scale/Tool Papers?
Top Non-Scale/Tool Papers?

Personal “Impact Factor”
Personal “Impact Factor”
Q. Who are the most influential authors in psychiatry?
Q Can influence by measured?

SURNAME INITIALS SPECIALTY Level

BAILEY SM C & A Psychiatry Platinum

FAIRBURN CJA General Psychiatry Platinum

GOODWIN GM General Psychiatry Platinum
LACEY JH General Psychiatry Platinum

MCKEITH IG Old Age Psychiatry Platinum

OWEN MJ General Psychiatry Platinum

THORNICROFT GJ General Psychiatry Platinum

WILLIAMS RJW C & A Psychiatry Platinum

APPLEBY LJ General Psychiatry Gold

BHUGRA D General Psychiatry Gold

BOLTON PF C & A Psychiatry Gold

DAVID AS General Psychiatry Gold

GILVARRY EA General Psychiatry Gold

GOODMAN R C & A Psychiatry Gold

GRUBIN DH Forensic Psychiatry Gold

HILL JW C & A Psychiatry Gold

HUNTER S General Psychiatry Gold

JONES PB General Psychiatry Gold

LEE AS General Psychiatry Gold

O'CONNOR S General Psychiatry Gold

PRIEBE S General Psychiatry Gold

SENSKY TE General Psychiatry Gold

STRATHDEE G General Psychiatry Gold

TREASURE JL General Psychiatry Gold
WILSON KMC Old Age Psychiatry Gold

ZIGMOND AS General Psychiatry Gold

Measuring Individuals Research
Measuring Individuals Research
Old Methods (counts)
• Subjective top 4 publications (RAE)
• Subjective top 10 publications (CEA form D)
• Total publications count
• Total Peer reviewed publications

New Methods (IFs)
• Total citations
• Citations per publication
• Citations per year (last 2 years)
• No. publications with same number of citations (H-index)
• Citations per year since qualification

Output Measured
Output Measured Results
78
found:

Sum of the
325
Times Cited

Average
4.17
Citations per
Item
h-index 12

“Exceptional” Output
“Exceptional” Output

Exceptional Citation Growth
Exceptional Citation Growth

Publication Count in Liaison (Anonymous)
Publication Count in Liaison (Anonymous)
500
464

450

400

350
292
300
243
250
203
200 183 183

150 134
114
87
100 78 77
69 67 61
42 40
50 26 21 18 17 10
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H-Index by Liaison Authors (anonymous)

3

Predictors of Journal Acceptance
Predictors of Journal Acceptance
• 1. Submitting the paper!
• 2. Proofing and high quality submission
• 3. Co-authorship
• 4. Choosing a low impact journal
• 5. Improving and re-sending after rejection
• 6. Selling in the Cover letter
• 7. Speaking with the editor
• 8. Getting an invited paper

Predictors of High Impact Citation
Predictors of High Impact Citation
• 1. Publishing in a high impact journal

“There was some delay in submission……. due to a backlog in the to do tray”

Citations vs probability article is online

Lawrence S. Online or invisible. Nature 2001;411:521
http://external.nj.nec.com/~lawrence/papers/online-nature01/

A comment from Rennie Drummond deputy editor
A comment from Rennie Drummond deputy editor
JAMA
JAMA
There seems to be no study too
fragmented, no hypothesis too trivial,
no literature citation too biased or too
egotistical, no design too warped, no
methodology too bungled, no
presentation of results too inaccurate,
too obscure, and too contradictory, no
analysis too self serving, no argument
too circular, no conclusions too trifling
or too unjustified, and no grammar and
syntax too offensive…..for a paper to
end up in print.

What is the Cost of Research?
What is the Cost of Research?
• CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness)
– National Institute of Mental Health (NIMH) clinical trial cost $67 million, with 1460
participants enrolled = $45,000 per patient for one year or $123 per day

• Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT)
– The National Heart, Lung, and Blood Institute (NHLBI) funding for Fiscal Years
(FY) 1993-2004 was $83,170,059, and 42,418 participants enrolled => $2,000 per
patient

• Diabetes Prevention Program (DPP) Clinical Trial
– Funding: FY 1994-2002 was $176 million and 3,234 participants enrolled (45% were
minorities). => $54,000 per participant

Pubmed vs Wok vs Scopus
Pubmed vs Wok vs Scopus
Pubmed
• 5,500 journals
• 18 million articles

Scopus
• 16,000

WOK
• 23,000 journals

Liaison Faculty09 - Research for NHS Clinicians [Workshop]

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