How to become a sub-specialist in emergency care research. St Emlyn’s

At a basic level emergency care clinicians should be trained in Good Clinical Practice and able to recruit to trials. However some will want to make research into a larger part of their work. This is the second blog in our series about emergency care research. We explore two career pathways for doctors wanting to have emergency care research as part of their jobs:  

  1. NHS clinician with an interest in research
  2. Clinical academic with a university appointment. 

The next blog in the series will share experiences from nurses, a paramedic and a physiotherapist.

Why sub-specialise in emergency care research?

All emergency care clinicians need a sub-specialty interest to give a balanced long term career. A whole career doing only ‘shop floor’ work is a recipe for burnout. Research gives the intellectual satisfaction of answering the questions which come up every day in clinical practice. It also provides a direct route to both quality improvement and personal learning. It also offers an opportunity to learn new skills, keep being challenged and working with a different range of colleagues.

NHS clinician with a sub-specialty interest in emergency care research

For doctors this type of emergency care researcher is employed by the NHS and may or may not have an honorary contract with a University. They are likely to focus on clinical research with the NIHR Clinical Research Network (CRN) being the main source of resources (in particular research nurses).

If an emergency medicine consultant their job plan may have one or two PAs (programmed activities, usually one equals four hours) dedicated to research, but they will also have to allocate some of their SPA (supporting professional activity) time to research.

There is a large variety in the way the research time is likely to be spent; as local Principal Investigator (PI) to multi-centre studies, undertaking evidence synthesis or as Chief Investigator (CI) to studies (with NIHR as a likely main source of funding). This route to research can be started at any time during a career and training may include part of the formal National Institute for Health Research (NIHR) integrated academic training pathway in England. Research performance is not usually reviewed as part of the appraisal process, but there may be an ongoing need to justify research time in a job plan.

Emergency care clinical academic employed by a Higher Education Institution

In England, this type of emergency care researcher is employed by a University, funded either through Higher Education Funding Council for England (HEFCE) funding to the University or by the University recharging the salary costs to a local NHS Trust. (There is a subtle difference depending where the funding comes from in the university politics around employment, with greater ‘kudos’ on HEFCE funding – but less independence for the academic). All university clinical academics also have an honorary NHS post. In emergency care academic job plans usually have a 50:50 split between University and NHS activity (although HEFCE funded posts in other specialties may have less than 50% clinical work).

Research time is likely to be spent as Chief Investigator (CI) on grant funded projects, with an emphasis on the research topics fitting in with the overall research strategy of the university. Time on non-income generating activities will be discouraged. There is an expectation that university academics should teach medical students – shop-floor teaching does not count here (as it is separately paid for by the University to the NHS Trust, so should be done in NHS time).

Research performance is reviewed annually with a focus on contribution to the university Research Excellence Framework (REF), which is what determines how much funding each university gets from the government. Clinical academics who do not perform well enough to enhance the REF return are likely to be asked to move to a NHS post, often keeping the honorary university ‘Professor’ title (this sideways move is easier if a university academic post is NHS recharged, so HEFCE funded clinical academics may feel a bit more secure). In the REF system clinical academics are counted as full time university employees (so in effect have half the time to produce the same outputs as non-clinical academic colleagues).

University employed clinical academics are expected to fulfil the administrative requirements of both University and NHS (for example two sets of mandatory training, duplicate annual leave applications etc) and have both a university and NHS appraiser for the annual appraisal system. In effect it feels like having two employers – each bringing their own set of expectations, requirements and pressures (and each assuming that you work for them full time!). 

Emergency care clinical academic with an honorary HEI appointment

The majority of clinical academics in emergency care hold NHS contracts and honorary appointments with HEIs. Honorary appointments allow clinicians to collaborate with HEI on research projects. The University of Manchester policy defines an honorary appointment as follows: “An honorary appointment is conferred on an individual in recognition of contribution equivalent in standing to that expected of the grade in question” (UoM honorary appointment). Honorary appointments are not remunerated by the HEI. 

An honorary university appointment does not allow a researcher to be “REF returned” (i.e. have their outputs counted towards future university income), and does not come with any expectation to do undergraduate teaching (above the normal NHS consultant amount). There is no university administration to perform and no requirement to attend university department meetings. The academic title (such as ‘Professor’) is the same for both substantive and honorary university posts, and to the outside observer there is little difference – however to the postholder there is a huge difference in what life is like! More info on terminology and responsibilities: clinical honorary appointments

NIHR Integrated Academic Training Programme

NIHR integrated academic training pathway

Medical school – integrated bachelors/masters and joint MBBS/PhD

Intercalated degrees offer an early opportunity to get involved in research and see if it is something you enjoy. Some universities offer specific emergency medicine and prehospital care intercalated degrees (e.g. iBSc in urgent and emergency care). A few medical schools offer joint MBBS/PhD programmes. If you enjoy research and want to develop your skills further have a look at the shortlisting criteria for SFP and the ACFs. With the scoring system in mind, think about how to maximise opportunities to meet the criteria.

Specialised foundation programme

After medical school, the SFP is a four month research, medical education or leadership block usually in the F2 year (specialised foundation programme). These are competitive applications that are made at the same time as the foundation programme. The AFP provides the chance to be part of research or develop your own projects, get mentoring and for some funded postgraduate studies. However, it is not essential to a clinical academic career to have pursued an intercalated degree or AFP. If you are keen to pursue an SFP in emergency medicine, it is a good idea to get in touch with clinical academics ahead of the application and discuss possible projects.

NIHR Academic Clinical Fellowship (ACF) – England

In England the NIHR Integrated Academic Training (IAT) programme for doctors provides a structured opportunity to combine clinical and research training (NIHR IAT programme). The first entry point is the ACF, which is a three year programme. You can enter it at different points throughout training including ST1, ST2 and ST3. Overall you have 9 months (25%) of protected research time. This can either be integrated with clinical time for example as 3 months a year during Acute Care Common Stem (ACCS) training. Or it can be a nine month block, which extends training. An ACF offers an opportunity to learn new skills and see if research is for you, as well as having access to mentorship and funded postgraduate studies and help with applications for PhD funding.

ACF posts differ in their content – so the best post depends on what type of research career you want. For an aspiring university academic it is pretty essential to look for an ACF post which is focussed on getting you a successful NIHR Doctoral Research Fellowship (DRF) application (i.e. is focused on the factors which score points in the DRF selection process).

NIHR DRF has a twice yearly application window. One launches in April for applications to be in by July and start date between April and September. The other launches in October to be in by January and start date between October and March. Logistically, it is advisable to be in the autumn application window to fit with the usual university start date for PhDs and it will help with staying in sync with the EM training system. As such front loading the academic time in the ACF is important to enable the ACF outputs to be included in the DRF application. For an aspiring NHS consultant with a sub-specialty interest, an ACF focused on research methods and delivery might be more appropriate and it is not necessary to front-load the academic time.

Herein are some tips if you are thinking about applying for an NIHR ACF in emergency medicine:

  • Think about possible projects and how they fit in with the research aims of the ACF location you are applying to.
  • Thoroughly read this website: NIHR Academic Clinical Fellowships (Medical) Guidance for Recruitment and Appointment 2021. It has the person specification, shortlisting criteria and interview questions.
  • Use Twitter to find current ACFs and ask them about the programme – pros and cons.
  • Email and arrange a conversation with the ACF programme leads and existing ACFs – find out about programme structure, research focus, how many have successfully gone on to PhDs or academic posts, opportunities for postgraduate studies, mentorship, other funding.
  • Have someone you trust read your white space questions and ask them to be as critical as possible. 
  • Bear in mind that for some of the ACF programmes in emergency medicine you will have to complete the clinical ACCS competencies in three quarters of the time. It is hard work!

There is a multiprofessional early careers researcher Forum supported by the NIHR incubator for emergency care. If you are currently doing an ACF or starting out in your research journey get in touch with Edd about the Forum.

NIHR Doctoral Research Fellowship – England

The NIHR DRF usually has three years of funding and allows up to 20% clinical time as part of the fellowship to maintain skills (NIHR DRF). NIHR provides advice on what makes an excellent application. It can be summarised as person, project, place and Public and Patient Involvement (PPI) (Excellent DRF applications). RCEM now recognises this clinical time can be used to demonstrate achievement of competences in the higher specialist training curriculum for doctors. 

Other funding bodies, including RCEM offer funding towards a PhD (RCEM doctoral fellowship). However, it is a much smaller contribution and often doctoral fellows have to find funding from multiple sources and make clinical/academic time split arrangements with local NHS trusts. It is possible to do an MD rather than a PhD, but this may be a disadvantage as it is regarded as lower calibre within a university.

There is a multiprofessional PhD Forum supported by the NIHR incubator for emergency care. If you are currently doing a PhD in emergency care get in touch with Edd about the Forum.

NIHR Academic Clinical Lectureship – England

For doctors an NIHR Academic Clinical Lecturer role offers funding for up to 4 years in higher specialist training with 50% clinical and 50% academic time (NIHR ACL). It is highly competitive (Emergency Care competes with far more established specialities who are searching for the cure to cancer). There are 100 ACLs available annually. Emergency medicine currently holds four ACL posts in England. It is usually postdoctoral post, where research skills are consolidated and the foundation (methodological and initial data) is laid for a large research grant application at the end of the ACL to smooth the path into the next rung of the academic ladder – applying for an Associate Professor (Senior Lecturer) post is a whole lot easier if you already have significant grant funding.

Personal awards for doctors – Clinician scientist, NIHR development and skills enhancement, NIHR advanced fellowship and NIHR research professorships

There is currently one senior lecturer/associate professor employed substantively by a HEI in Scotland and none in England and Wales. So unless a university decides to include emergency care as part of their strategic research plan, obtaining a personal award is the best way of getting a post.

The NIHR Advanced Fellowship NIHR Fellowship Programme | NIHR gives payment of salary for 2 to 5 years, making the creation of an academic post much more appealing to a university. There needs to be some advanced discussion between the NHS head of department, the Dean of the Medical Faculty and the potential applicant well in advance, so that any potential new post can be included in annual planning cycles. These are highly competitive posts, Edd is currently the only one in the UK from emergency care. It requires a substantial track record in terms of publications and securing grant funding.

There are also NIHR research professorships (England only) and global research professorships (all UK) available that emergency medicine clinical academics can apply for (NIHR research professorships). However to date no emergency care clinicians have been awarded one of those roles. 

NIHR development and skills enhancement awards are open to post-doctoral clinicians and provide one year worth of funding. The current strategic themes are: health data science; clinical trials and entrepreneurship and working with industry. An emergency medicine consultant holds a health data science fellowship (Development and skills enhancement award). 

Clinician scientist award is a postdoctoral fellowship with funding for up to five years on average. It is often awarded to doctors in higher specialist training and can be used to transition into a consultant post and carry on with research activity Clinician scientist award. There is currently one emergency medicine consultant that holds a clinician scientist award.

Devolved nations academic programmes for doctors

For more information on the available clinical academic training opportunities in the devolved nations check out:

Northern Ireland: Northern Ireland ACF and ACL

Ways into research before the integrated academic training pathway

However, this isn’t the only way into research and most of the more senior emergency medicine researchers and academics did not have a training path to follow. Tim – we carved out bits of time and funding with most academic work being done in our own time on top of full time training. For some of my training I did a ‘deal’ with the emergency department, where in exchange for some research time I did a much higher proportion of evening and weekend shifts – giving a mutual benefit as I had some research time and the ED had better out of hours cover (although maybe not giving so much benefit to my personal life!). I was able to do an MD as a sympathetic supervisor in neurosurgery employed me on income from a drug trial (the first trial of nimodipine in SAH) so that I delivered the drug trial, which did not take up all of my time so I could also do my own research with the London HEMS system. Both of my university academic appointments came about because the local NHS Trusts wanted me to work for them, so persuaded the local University to create an academic emergency medicine post. 

Edd – I may be a little “against the grain.” I didn’t take a traditional academic path. I began research at ST4 level with a £10K grant from RCEM and managed to top up my part time salary with a PhD Studentship through a local university. I took a vow of academic poverty during my registrar years but it has been worth it. When I began as an NHS Consultant I had no academic time. However, leading on from my PhD I was able to apply to my Trust to secure Research Capability Funding (all trusts have a pot of money that employees can apply to gain job-planned time for grant development). This allowed me to have a small amount of time to develop a large grant to the NIHR Research for Patient Benefit Scheme to undertake the LoDED Trial (https://heart.bmj.com/content/106/20/1586). Having delivered this I gained the trust of the NIHR and I haven’t looked back. I am still employed by the NHS but have 60% research time which has been built up through an NIHR Advanced Fellowship. I am really proud to say that my 10K RCEM grant from 2015 has been converted into over £3 million funding from the NIHR and I am now leading big emergency medicine multicentre randomised trials that are important to the future of our specialty. My career now is far more sustainable and enjoyable as a result.

Opportunities to develop an emergency care research portfolio

RCEM Professorship/Associate Professorship

The RCEM associate / professor posts were created as we have too few professorial posts in emergency medicine and NHS employed EM academics making grant applications were bening disadvantaged as they did not have an academic title or the academic track record of our competitors (RCEM professor). The RCEM posts aimed to assist research active emergency physicians by giving a status in order to get into the academic system, engage with academic support and strengthen their argument for resources. They were not intended to be a “well done medal” for already successful researchers.

Edd- Undoubtedly the RCEM Associate Professorship has opened doors. There is something in the name (or email signature) that makes people take notice and want to collaborate. I have recently taken on the RCEM Professorship role and continue to support TERN, RCEM grants and helping our specialty grow academically.

NIHR Funding

The formation of the NIHR has been the biggest recent change in funding research, and emergency care continues to do very well from this change. The opening up of NIHR funded training opportunities has been a game-changer, allowing emergency medicine trainees and consultants and emergency care nurses and AHPs with an interest in research to develop skills and experience in a way that has not previously been possible. The multiple funding streams and the ‘horizon scanning’ that includes RCEM as a partner have given big opportunities for emergency care clinicians to undertake large clinical research projects which matter to our patients. There are plenty of good examples around the UK of emergency medicine consultants becoming active researchers with the support of NIHR funding to conduct trials and undertake other studies.

RCEM Grants

The RCEM grants are a great place to start a research project. Applying for a large NIHR grant often requires some preliminary data, which can often be achieved by the relatively small amount of money available through the College. As RCEM is a NIHR Partner the delivery of research projects funded by RCEM is automatically prioritised for CRN support (research nurse salaries etc), which can often be many times the value of the initial grant.

NIHR Associate Principal Investigator Scheme

For nurses, AHPs and trainee doctors becoming an Associate Principal Investigator is a great way of getting started (Associate Principal Investigator (PI) Scheme (nihr.ac.uk). Every EM PI should look at making an opportunity available for an Associate PI. This would make a huge difference to EM research training – allowing junior doctors, nurses and AHPs to get a ‘taste’ of the reality of delivering clinical research. Thomas – I am associate PI for the RECOVERY trial at Manchester Royal Infirmary and it has been an excellent experience. Learning about how to set up and run a clinical trial, as well as working with different colleagues and consenting patients. I highly recommend it to junior doctors, nurses and AHPs.

NIHR Emergency Care Incubator

Contact the Emergency Care Incubator (nihr.ac.uk). The Incubator intends to shine a spotlight on research in emergency care, enhancing mentorship, training and support for clinical academics, as well as creating a core community, enhancing recruitment and retention, and ultimately building research capacity and delivery. If you cannot find a local mentor for research see NIHR Incubator for Emergency Care – RCEMLearning.

How to get your emergency department started in research

Things to do if you want to get your Department research active:

  1. Talk to your local CRN ‘Injuries and Emergencies’ lead. Find them through the NIHR website.
  2. If there is an already research active ED nearby – go talk to their research lead.
  3. Enthuse your consultant colleagues and managers about the advantages of the Department becoming research active.
  4. Talk to your Trust R&I Clinical Lead about getting some ‘pump priming’ resources to set up your Department’s first study (PA time for you and some research nurse support).
  5. Ask the CRN manager for your region to put you on the mailing list for upcoming emergency care studies.
  6. Find an upcoming study being run by one of the large Clinical Trials Unit (so you know it will be well supported) and volunteer to be a participating site.

Challenges in emergency care research

Competition for emergency medicine academic training places – in 2020 seven universities in England advertised for emergency medicine ACFs. However, only 2 were recruited. In ACF recruitment, emergency medicine trainees often have to compete with other specialties, which are more established with higher research output, such as cardiology and surgery. This competition continues for NIHR DRFs, ACLs and Advanced Fellowships. 

Lack of diversity in emergency medicine academic roles – There are more professors of emergency medicine named Tim, than there are women. All professors of emergency medicine are white. How can people become what they don’t see? This lack of diversity hinders who applies for academic posts. 

Pipeline of clinical academics in emergency medicine – the lack of emergency medicine doctors in ACF, ACL, senior lecturer and associate professor posts hinders the development of the academic specialty. 

EM research is threatening to other specialties – some specialist researchers see EM research as being a ‘land grab’ for the resources currently given to research at the acute end of their own specialty. This can lead to attempts to suppress or marginalise EM research. However, delivering clinical research in the emergency setting is a specific skill set and working in collaboration with specialties can mutually enhance the chances of successful grant application.

Time – the administration of research takes a lot of this, which most clinicians do not have. A skilled research nurse able to take the admin load of site file maintenance and governance correspondence is invaluable. Also in IAT posts you often still have to spend time outside of designated academic blocks, preparing projects, reviewing papers and applying for ethics and funding. 

Keeping enough clinicians ED with current GCP certificate and CV in the site file – undertaking GCP training is yet another ‘ask’ to busy clinicians who have difficulty finding the time to undertake this additional regular retraining. This means that it is difficult to keep a critical mass of clinicians able to recruit patients to clinical studies.

Getting CRN support – although all NIHR, Industry and NIHR Partner funded studies are supported by CRN resources, the resources available are insufficient to support all studies, so there is competition – high recruiting low ‘cost’ studies are preferred.

Cost of ED studies – many ED studies have a high cost as recruitment, especially consent processes in acutely ill patients, can be complex. Studies which are low volume and high cost tend to have a lower priority for support.

Timing of ED recruitment – most research teams recruit patients from 08:00 to 18:00, but the needs of ED studies are different as our patients often arrive ‘out of hours’. This may make recruitment less than expected.

Patient input – emergency care is usually a brief part of the patient journey through the healthcare system, so it can be difficult to find engaged patients to give PPI input (which is needed at an early stage of development of any project, especially if applying to NIHR funding streams).

No dedicated time for research – Even with some job plan research time it is difficult to do research in work time. Most EM researchers undertake a significant proportion of the research work in their own time. This discriminates against those with commitments outside of working hours.

Most grant applications fail – Success rates to the major funders are often <20%. This can be very depressing and demotivating, especially as there has been a large amount of work put in and there is often relatively little feedback as the process has a large element of chance about it (in a hugely over-subscribed and competitive process just one panel member saying “not sure about this one” can be enough to put an application on the reject pile). 

Researchers from all specialties need to develop strategies to cope with failure (as you will fail 4 times out of 5!). We have also all collectively got many stories of manuscripts being rejected at desk review. Most journals we try to publish in have very low acceptance rates. Another thing to get used to and develop a thick skin for. 

Get in touch

If you want to know more about clinical academic careers in emergency care, please feel free to get in touch with any of us. Thomas Shanahan is the EMTA research representative, ST2 in emergency medicine and an NIHR ACF and is happy for you to contact him on Twitter @clifford0584. Tim Coats is a Professor of Emergency Medicine at the University of Leicester and can be found on Twitter @TJCoats. Edd Carlton holds an NIHR advanced fellowship and is RCEM Professor and co-chair of the NIHR incubator for Emergency Care. You can get in touch with Edd via Twitter @EddCarlton.

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