Dr Karen Stuart-Smith

Consultant Anaesthetist and Contributing Editor, Anaesthesia Product News

Q: Why are you interested in research?

A: Probably my slightly unusual family background had something to do with it. My father was a Consultant Physician and Senior Lecturer in Medicine in Glasgow. He was a rather focussed career man. I was the eldest of four children, and whenever my mother was having another baby, I was left with the technicians in my father’s lab while he did his ward rounds. This was a rather alternative form of baby-sitting but I understood the principles of electron microscopy and gas chromatography by the time I was 12. Not that I was particularly bright – there’s just a limited number of things to entertain a child in a lab! Health and safety issues wouldn’t allow this method of child care these days, but it introduced me to the idea that you could ask questions about the world around you and then use laboratory techniques to answer them. Even so, I was so determined to be different from my father that my initial choice for University was agricultural chemistry (don’t ask). It was a summer job as a nursing auxiliary that made me realised I enjoyed interacting with patients, and I switched to medicine at the last minute.

Q: Why anaesthesia?

A: I found that I was really interested in the mechanism of how the body works, both at whole animal and cellular level. I did an intercalated degree in physiology, and became very interested in vascular physiology and pharmacology. When I went back into medicine, I realised that anaesthesia was best suited to my outlook, with its strong emphasis on physiology and pharmacology, particularly related to the cardiovascular system.

Q: What is your biggest research influence?

A: My earliest research influence was (then Dr, now Professor) JC McGrath at the University of Glasgow. As an undergraduate I went to a talk he gave about arterial adrenoceptors and was immediately hooked (sad but true). I left a message on his desk saying I would like to work with him and the rest is history. By sheer chance, immediately after graduation I ended up working in Professor Paul Vanhoutte’s lab at the Mayo Clinic. I’d been introduced by a friend of mine who told me about exciting new work on the endothelium, and how something from it caused vascular smooth muscle relaxation. Of course this was ‘endothelium-derived relaxing factor’, or nitric oxide. Paul’s lab was one of the foremost endothelium labs of the day, and as this was the era around the discovery of nitric oxide, it was a very exciting time. Anyone who thinks research is a gentlemanly pursuit ought to experience the cut-throat atmosphere at the edge of new discoveries. I was a very young and naïve post-graduate fellow. I didn’t even realise Paul Vanhoutte was famous in his field until I’d been at the Mayo Clinic for several months! I learned a great deal about science during my two years there, including how to set up and run a project, write papers, and read original research with a sceptical eye. Paul Vanhoutte is a great communicator and vastly improved my ability to give lectures and present data. I still teach these same techniques to junior anaesthetists and science students today. Paul has written many reviews on endothelium aimed at a clinical audience. He believed it was possible to make science accessible and interesting. I have always subscribed to this view and this philosophy is behind all the articles I write for APN. Science doesn’t need to be complicated and couched in obscure language in order to be credible.

Q: What is your perspective on academic anaesthesia in the UK?

A: Overall, things are definitely looking up and I feel more positive about the future. This was not always the case! Although I did my basic anaesthesia training in Glasgow, I spent several of my post-fellowship years in research and/or clinical posts in the United States, including a spell as an attending anaesthesiologist at Johns Hopkins. Although research in the States is challenging and intensely competitive, the university system is more informal and less hierarchical. The quality of your research is more important than your status. Above all, it can be exciting and fun, especially at junior level. When I returned to this country permanently in the mid-1990s (for personal reasons), it was a profound shock to realise that in British anaesthesia, research was generally regarded as a haven for the eccentric and the clinically inept. Working in theatre or intensive care was real man’s work, whereas research was nothing more then navel contemplation. Related to this viewpoint, basic science was (and to a large extent still is) regarded as irrelevant to anaesthesia practice. Although all branches of academic medicine have suffered a decline in the last 20 years, the spectacular decline of academic anaesthesia can be directly linked to these bizarre attitudes. It didn’t help that university departments of anaesthesia were extremely hierarchical, and juniors were seen but not heard. This was really the difference between American and British academia. Respect for one’s elders is a necessary part of departmental discipline, but if junior members of a department are discouraged from offering a contradictory opinion, or putting forward new ideas, the department is starved of oxygen and quickly dies. Academia in the UK seemed to run out of steam in the late 90s. I was frequently informed that as anaesthesia was ‘safe’, no new research was needed. This view was so pervasive that it infected national grant-awarding bodies such as the Medical Research Council. No new ideas meant no grant funding and hence no research, so many departments were shut down by the parent universities. Unfashionable, uninspired and regarded as irrelevant even by anaesthetists, it is not surprising that academic anaesthesia was nearly brought to its knees. Recent developments at the Royal College and Association (reported elsewhere in this issue of APN) with regard to the establishment of a national body to promote research in anaesthesia is a very welcome development. As anaesthesia is primarily a service speciality, many hospital Trusts regard time allocated to research as an unnecessary diversion from the business of delivering government targets, and as anaesthetists themselves have historically placed such a low premium on academia, it has been hard to argue against this. A national body will help to improve our credibility. However, we are starting from a very low base. Many of the anaesthetists who expressed the views outlined above to me with force and feeling, are still in practice and still feel very negative about research. Hopefully such viewpoints will gradually become a minority!

Q: Tell us about the Anaesthesia Research Trust

A: Establishing my own research credentials in UK anaesthesia was a difficult and painful process. I am strongly motivated by a desire to help others avoid the hoops I had to jump through. The final precipitating factor that propelled me to form the Anaesthesia Research Trust was watching juniors being mauled by their elders at a research meeting in a dusty and depressing lecture theatre. I felt that it was imperative to create a research meeting with the informal atmosphere and sense of excitement that I had experienced as a junior research fellow in the States. I also want to show juniors that presenting at meetings can be relevant and fun.

Although as Mayo Clinic Fellows we always took great care that our abstracts were accurate, interesting and relevant, there was an important difference in the way meeting abstracts are generally regarded in the UK. An abstract should be a summary of work in progress, which you take to a meeting to get feedback from others working in the same field, and from senior researchers. This allows flaws to be detected early and flags up potential concerns that a reviewer might have when the full paper is submitted. Such a philosophy has helped to steer my research several times.

The concept of UK meetings, that abstracts should be a summary of completed work, puts a damper on discussion and stifles the free exchange of ideas. It also encourages malicious criticism, as once a project is effectively completed, it is almost impossible to go back and change it.

The abstract then becomes nothing more than a record of failure. No wonder many juniors become discouraged and feel research is a pointless waste of time. A word about audit presentations. It is hard enough for juniors to get any audit done, especially as they only stay in any one hospital for a maximum of 5 minutes. Completing an audit loop means doing an audit, persuading managers and/or clinical colleagues to make relevant changes, and then re-auditing the process to see if improvements have occurred. Getting changes made to even the most minor process in the NHS takes several months or years, so that the auditing junior might be a consultant by the time suggested changes are made! As consultants ourselves we have great difficulty getting changes made. Expecting a single junior to do so within a six month or even year-long rotation is frankly ludicrous.

Carping at individuals in a pompous manner because they have not been able to do the whole thing themselves is extremely counterproductive, and leads to juniors ditching the whole concept of audit as soon as their CV no longer requires it. We need to accept that audit presentations will always be works in progress, so that incoming juniors can pick up where the previous ones left off, and all can present their contribution to the overall audit loop at meetings.

For all of these reasons, I formed the Anaesthesia Research Trust, a registered charity, which came into being in 2004. The aim of the charity is to promote understanding amongst anaesthetists of the relevance of research and technological innovation to improving patient care. The National Anaesthesia Research Meeting (NARM), which has its 4th running in October 2008, is designed to be informative, exciting, informal and fun. Although submitted abstracts have to conform to basic ethical, clinical and statistical standards, the bar is set deliberately low. In recognition of the difficulty faced by most juniors in attempting to undertake research, audit and case reports are also welcomed. Abstracts are expected to be works in progress, and advice is given on how to progress with a particular project and how to present the data. The idea is to show that discussion has value, and that research is worth the effort. By targeting anaesthetic trainees early in their career, I hope to promote a very different and open attitude to research, in marked contrast to the barren and hostile atmosphere I endured. I hope I can achieve this aim.

For further details of the Anaesthesia Research Trust, please visit www.anaesthesiaresearch.org.uk