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Are you a successful researcher?
Well, it depends on who’s asking
Simon Noble
I have, on fi le, a very polite letter from a
palliative care journal explaining that it
would not be sending my paper out for
review, since it covered a topic that was
not of relevance or interest to the target
audience. The editor kindly wished me
every success in my future research.
That letter had a profound impact on
my academic career. I rationalised that
rather than my rejected paper being of no
interest to the palliative care readership,
it was just not the right time to consider
the conclusions I had drawn. We are still
a young specialty; academically even
more so. Challenging the established
view, however well intentioned, may
be interpreted as discourteous rather
than a pursuit of academic rigour. My
resolve was further strengthened when
later that year an Australian gastroenter-
ologist Barry Marshall along with Robin
Warren was awarded the Nobel Prize for
Medicine for the discovery of Helicobacter
pylori and its role in gastritis and peptic
ulcer disease. Initially published in the
Lancet in 1982, Marshall’s work attracted
little interest at the time.1 The majority
of the medical establishment rejected
his work with one prominent gastro-
enterologist branding him ‘a crazy guy
saying crazy things.’ It wasn’t until 1994
that the causative association between
H pylori and peptic ulcer disease became
widely accepted, and the use of eradi-
cation therapy transformed the lives of
millions of patients worldwide.
The moral of this tale is not that
if you wait long enough, your previ-
ously ridiculed research will earn you
a date in Stockholm, courtesy of the
Swedish Academy. Rather, it highlights
two important points about research:
fi rst, some ideas are ahead of their time
and not readily accepted by the scien-
tific community. Second, the impact of
new research may take several years to
manifest.
Correspondence to Simon Noble, Palliative
Medicine, Cardiff University, Royal Gwent Hospital,
Cardiff Rd, Newport NP202UB, UK; Simon.Noble@
wales.nhs.uk
BMJ Supportive & Palliative Care September 2012 Vol 2 No 3
So how does one defi ne success in the
context of palliative care research? By
the number of papers published? The
number of citations a paper generates?
Through the impact your work has on
patient care? Or perhaps through the rec-
ognition one gets from one’s peers?
Palliative care is the one area of
healthcare every patient will eventually
require; yet the evidence base informing
our practice is still patchy at best. In the
absence of robust clinical evidence, we
treat our patients according the best data
we have; sometimes based on observa-
tional work, audits or extrapolated from
studies conducted in non-representative
patient groups.
The challenges to conducting high-
quality research have been discussed
extensively in the literature.2 Identifying
the population that is to be studied can
be difficult since no universally accepted
defi nition of the ‘palliative care patient’
exists within clinical or research settings.
Likewise, the holistic nature of our spe-
cialty is such that the pathophysiology of
common symptoms are recognised to be
complex and multifaceted, encompassing
spiritual, psychological and social com-
ponents to the physical manifestation of
common symptoms. Studies to improve
the symptom burden in palliative care,
therefore, may require novel methodolo-
gies alongside complex interventions and
evaluations; outcome measures embedded
within cancer studies may not be appro-
priate in people with advanced disease.
The ethical issues around research in
the hospice setting have been suggested
as a barrier to palliative care research for
some time and are often cited as a key
reason for poor recruitment to trials.
The fact that such paternalistic practices
further prevent the pursuit of evidence-
based treatments for our patients is
ethically difficult to justify. Participant
attrition has frequently been cited as a
reason for failure to complete studies,
when often the failure is a reflection of
the study design and execution.
The bottom line is this: until research
in our specialty becomes custom and
practice in all the healthcare settings
Editorial
wherein we work, we will rarely be able
to conduct the randomised controlled
trials necessary to answer the impor-
tant questions facing clinicians every
day. Until this happens, there is a risk
that researchers will continue to work
in their individual silos producing poorly
powered studies of little statistical signif-
icance and dubious clinical relevance.
These challenges were recognised
some time ago; in 2004, the National
Cancer Research Institute’s (NCRI) stra-
tegic review identified the need to build
research capacity in UK supportive and
palliative care (SuPaC) research noting
that only 4.3% of direct spending on can-
cer research by NCRI partners was being
directed at SuPaC activities. 3 A need for
more research collaboration and inter-
disciplinary working was highlighted
and in response to this, a consortium of
NCRI partners set up the Supportive and
Palliative Care Research Collaborative
scheme.
Two collaboratives were awarded
funding of £1.9 million over 5 years to
increase research capacity in the United
Kingdom, commencing in 2006. In this
issue of BMJ Supportive and Palliative Care,
members of the Cancer Experiences
Collaborative (CeCo) evaluate their suc-
cess of research capacity building (RCB)
against Cooke’s six principles of RCB,
namely training, supporting research
close to practice, establishing collabora-
tions, dissemination, sustainability and
infrastructure.4 Their paper asserts that
their activities have contributed signifi-
cantly to RCB, in particular through edu-
cational activity, grant acquisition and
dissemination of results through peer-re-
viewed journals. What neither Cooke nor
the NCRI are clear about is the degree to
which one should deliver on each cat-
egory to make the grade.
With a grant acquisition of just under
£19 million over 5 years and 547 publica-
tions, the collaborative’s success against
these outcomes is impressive. The
authors identify that 18% of grants and
15% of publications arose directly from
CeCo activities, and argue the majority
arising indirectly from CeCo activities
demonstrates the ‘added value of the intra-
structure support, networking, meth-
odological expertise and senior research
mentorship that accrued from this col-
laborative’. What will never be known is
how many of these successes would have
been realised without the CeCo collabor-
ative; with the original grant applicants
including eight professors, academics
arguably at the top of their game, with
207
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Editorial
already established credentials in grants-
manship and publishing papers. It is not
clear how much of the grant income was
through open peer-reviewed competition
and thus entitled to ‘badging’ under the
auspices of the NCRI. This is important
since such quality measure brings with
it National Health Service infrastructure
and trials support.
Success will differ according to the cri-
teria against which it is measured; CeCo
members will also need to prove their
worth within their own academic insti-
tutions. With the Research Excellence
Framework (REF) 2014 just around the
corner, universities have an expectation
of their staff to return publications in
high-impact-factor journals and dem-
onstrate an impact of their research on
practice. Of the 547 papers published,
it would be interesting to know how
many of these would be REF returnable;
an author of four high-quality academic
papers will evaluate better than someone
producing considerably more publica-
tions in lower-impact journals.
The true success of the RCB strategy
will not become apparent until we can
evaluate whether the outputs of the col-
laboratives are sustained. Only in time,
will we see if researchers supported by
the collaborative maintain and grow their
activities and continue to work across
institutions as intended. One would sin-
cerely hope that if the NCRI were to con-
duct a review of SuPaC research in the
future, its fi ndings would be considerably
208
different to those in 2004. As the authors
correctly conclude, the ongoing ‘chal-
lenge is to retain collaboration to support
RCB rather than revert to small scale
single researcher studies with potentially
less impact.’
It is beyond the scope of this paper, to
evaluate how evenly the collaborative
programme has built research capacity
across the whole UK; of the 23 NCRI
funding partners, four contribute monies
specifically from the devolved nations,
and the majority of the others have
fundraising activities beyond England
alone. It would be an interesting exercise
to evaluate the degree to which RCB in
Northern Ireland, Scotland and Wales
has developed through this strategy.
From their paper, CeCo appear to have
delivered what was asked of them by
the NCRI, and one hopes that the end
of the collaborative funding stream can
be viewed as the beginning of a new
era in SuPaC research within the UK.
However, if we aspire to undertake high-
quality research we should now consider
whether our focus would be better aimed
at developing and supporting more ran-
domised clinical trial activity. This has
been done successfully by colleagues in
Australia for some time. 5 In a continent
31 times larger than the UK, yet with one-
third the population, the colleagues from
the Australian Palliative Care Clinical
Studies Collaborative are successfully
recruiting to a programme of appropri-
ately powered randomised control trials;
BMJ Supportive & Palliative Care September 2012 Vol 2 No 3
the research questions they ask are sim-
ple, focused and relevant. Already we are
seeing their endeavors disseminated in
high-impact academic journals. So once
again, as with Barry Marshall, I take my
inspiration from down under.
‘And how did it go with that rejected
paper?’ you may ask. Well, I waited a while
and then published it somewhere else.6
Competing interests None.
Provenance and peer review Commissioned;
internally peer reviewed.
Accepted 16 June 2012
Published Online First 16 July 2012
BMJ Supportive & Palliative Care 2012;2:207–208.
doi:10.1136/bmjspcare-2012-000301
REFERENCES
1. Marshall BJ, Warren JR. Unidentified curved bacilli
in the stomach of patients with gastritis and peptic
ulceration. Lancet 1984;1:1311–1315.
2. Jordhøy MS, Kaasa S, Fayers P, et al. Challenges
in palliative care research; recruitment, attrition and
compliance: experience from a randomized controlled
trial. Palliat Med 1999;13:299–310.
3. National Cancer Research Institute. Supportive and
palliative care research in the UK: Report of theNCRI
strategic planning group on supportive and palliative
care. London: NCRI 2004.
4. Payne S, Seymour J, Grande G, et al. An evaluation
of research capacity building from the Cancer
Experiences Collaborative. BMJ Supp Pall Care.
5. Shelby-James TM, Hardy J, Agar M, et al. Designing
and conducting randomized controlled trials in
palliative care: a summary of discussions from the
2010 clinical research forum of the Australian Palliative
Care Clinical Studies Collaborative. Palliat Med 2011.
6. Noble SI, Nelson A, Turner C, et al. Acceptability of
low molecular weight heparin thromboprophylaxis for
inpatients receiving palliative care: qualitative study.
BMJ 2006;332:577–580.
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Are you a successful researcher? Well, it

depends on who's asking
Simon Noble

BMJ Support Palliat Care 2012 2: 207-208 originally published online July
16, 2012
doi: 10.1136/bmjspcare-2012-000301

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