A PhD thesis in knowledge translation: Improving medical management through research and training

When I tell people that I have been doing clinical research for the better part of my last decade of life I usually get a few or more of the standard questions that are asked of higher degree research students like, “what did you do your PhD on?”, “what did you find?”, “was it hard?”, “why did you do it?”, and “what’s next?”.

These questions can be asked in a matter of seconds, but to answer them even briefly can take from 15 minutes to hours, depending on the level of interest. Now that the PhD is finally wrapped up, I feel inspired to write down some of the answers to these questions. I write in the spirit of what my thesis was all about “knowledge translation”, in other words, getting research off the shelves and into practice.

What was your PhD thesis on?

The title was “Improving the medical management of organophosphorus poisoning (OP) throught health services research and training”. Self harm is a big problem worldwide, and anyone working in an emergency department will be no stranger to this problem whether it is from people cutting themselves or taking overdoses. In many parts of rural Asia people drink pestices as a means of self harm resulting in over 300,000 deaths annually.

The vast majority of these pesticides are a particular form called organophosphate agents. This is much more toxic that the common weed killers used in Australia, such as round-up which is a glyphosate, and organophosphorus agents result in high case fatality rates, in the order of 15-30%, despite best practice.

The research collaboration that I worked with to conduct my research, the South Asian Clinical Toxicology Research Collaboration (www.sactrc.com), was a project that aimed to address many aspect of the public health problem of pesticide self-poisoning.

My work focussed specificially on two areas;

1) Improved medical management through the use of point-of-care tests that could provide information (acetylcholinesterase, ACHE, levels) that was thought to be useful in guiding antidote therapy
2) The evaluation of a train-the-trainer system of education to address training deficits in resuscitation education in the rural Sri Lankan setting

Both of these streams of study were different vehicles on the same journey of aiming to close the knowledge practice gap surrounding the management of OP poisoning. Thus the overall theme of my thesis was to do with this process of “knowledge translation”. The studies have been liked together using this conceptual framework.

They say a picture says a 1000 words so perhaps a figure from the introduction section of the thesis of the conceptual frame work , and two figures from the conclusions sections would aid to this strategy (ie 3000 words!?)

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fig 3

Was it hard? Why did you do it?

These two questions are perhaps best answered together.

Yes it was hard.

I did it for multiple reasons, but most of all, it was the journey of trying to make a difference in the world. I have always wanted to do this, and when I started doing educational research I realised that there is an immense potential to improve the world by creating, and then assessing different systems of education.

The following video/slideshow shows how this happened in a poetic format.

The course of the PhD offered many challenges for my Emergency Medicine training that I was doing concurrently, as well as the ups and downs of life.

However, despite the knocks and triumphs, I strengthened my resolved to follow the dream I initially had with making a difference through training in Emergency Medicine training and International Research, and so far it has paid off in ways that I cound’t have imagined.

What’s next?

The first step was to stop, appreciated, and then reflect upon lessons learned, and wisdom gained that will hopefully help myself and other in the future. The next step is to become an Emergency Medicine consultant by finishing off the training, through training and sitting a fellowshop exam next year in 2016.

As for the future, I have some dreams and visions. I would like to continue as a clinical academic, teaching medical students and junior doctors. The vision I have is to help address many challenges in health care training, by fostering better “systems of training and education”. Perhaps one way this could be done is through research that also takes into account the important human factors of communcation and compassion, but who knows – tomorrow is still a mystery?

Some key publications;

The Effectiveness of a ‘Train the Trainer’ Model of Resuscitation Education for Rural Peripheral Hospital Doctors in Sri Lanka – Plos One (2013)

Evaluation of the Test-mate ChE (Cholinesterase) Field Kit in Acute Organophosphorus Poisoning – Annals of Emergency Medicine (2011)

Effect of acetylcholinesterase (AChE) point-of-care testing in OP poisoning on knowledge, attitudes and practices of treating physicians in Sri Lanka (2014)

PDF of Thesis

Current research projects;

Enhancing employee engagement and wellbeing in at risk units

 

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PhD Thesis – the story behind the questions..

I was once told that good writing is all about the narrative. When I started writing up my doctoral dissertation I soon learned that I was collating, and weaving together, a series of narratives into a cohesive story with some scientific value.

I also learned that the key to good research is having useful and relevant research questions. In my thesis some of the most important questions only came clear to me whilst I was already on the ground doing research in a rural hospital in Sri Lanka. Here, I remember vividly observing many critically ill patients who had intentionally consumed deadly pesticides, and wondering what their fate would be given and how we could improve the medical management in order to save lives. Thus, for me it made sense to try and provide a story about the “context” where I embodied the research questions that would culminate into the ensuing scientific narrative.

Below is a poem that never made it into the final thesis, but in perhaps captures the passion of enquiry that sustained me through the long journey of formulating hypothesises, collecting data, and publishing my final findings.

Too young to die

Side by side in the intensive care they lie,

Multiple family members hoping they won’t die,

I can’t help but ask myself why,

Surely this lady is too young to die?

.

Was this the result of frustration in the home,

Did she really want to leave this world for good?

Would her family and kids not worry and feel pain,

Everything seemed like it was all in vain,

.

Back to the room with the lights and the constant beeping,

Things are getting tense, she is more than sleeping,

Deep down I feel strongly that this lady should not go now,

I want to help, but the real question was “how”?

14/2/07 (21:24hrs)  The above poem was written whilst observing a 36 year old woman, from a rural town in the north central province of Sri Lanka, fight for her life whilst on an intensive care ventilator. She was the mother of 3 children, and took an organophosphorus pesticide poison following an argument with her husband. She died within 2 days of presentation to hospital.

My PhD research was dedicated to the countless patients, like this lady, and to the numerous health staff and researchers who who were all a part of the effort to save and improve these patients lives.

The following two PDF excerpts show the contextual story which lead to the eventual scientific document that comprised the final thesis.

A strategy for hope in the face of death…

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Download here (phd-thesis-preface )

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The table of contents

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phd-thesis-table-of-contents

The entire thesis can be downloaded from ANU digital thesis at this link  – however, I’m happy to be emailed (bishan.rajapakse@gmail.com) and send you a pdf copy if you would like to read it. I would also be delighted to hear any reflections or comments on this work that occupied my attention for the better part of a decade.