Collaborative research in Australasian plastic surgery

Alone we can do so little; together we can do so much.
—Helen Keller

The specialty of plastic surgery is diverse, covering almost all of the body and embracing a wide variety of techniques to restore form and function. By necessity, plastic surgery is a broad church, with individual practitioners spanning the spectrum from generalists to those who have very subspecialised practice in one or a few fields based on their interests and local service needs. While subspecialty craft groups, dedicated meetings and specialist societies all help to raise the standard of clinical care and foster innovation, it is high-level evidence from clinical research that best informs and directs clinical care. Unfortunately, it is difficult to achieve adequately powered, high-impact research in a timely manner when such subspecialisation exists. This is particularly the case in places like Australasia where populations are geographically dispersed and local data collection is often underpowered to achieve statistically (let alone clinically) significant findings. This problem is not unique to Australasia. Plastic surgery research (and surgical research more generally)¹ suffers from a lack of high-quality clinical research. In plastic surgery alone, meta-research has shown an abundance of cohort and case series, many are single-centre.^2,3 Collaborative research could solve this but it is challenging without pre-existing pathways. Consequently, the lack of robust mechanisms to support local, national, and international collaborative research is an important factor in the persistently low level of evidence that predominates in the literature.

Many specialist groups have developed clinical trial initiatives in response to the growing need for more collaborative research, and these are proliferating in multiple countries across the globe. They function by providing a framework, resources, expertise and established pathways to support all levels of surgical research from audits to randomised controlled trials. Furthermore, their aim is not only to provide research pathways for fellows and trainees but to also foster future generations of surgeons to develop skills in surgical research by providing opportunities for pre-SET trainees, junior doctors and medical students to participate in and lead appropriate clinical studies. Similarly, collaborative projects with allied health practitioners can provide research learning opportunities and assist surgeons to capture meaningful patient outcomes. The Royal Australasian College of Surgeons (RACS), under the direction of Professor John Windsor, established the clinical trials network of Australia and New Zealand (CTANZ)^4,5 based on a similar, successful UK initiative^6,7 to achieve these aims. Professor David Watson is the current chair of CTANZ, which has supported the development of multiple surgical speciality-specific sub-initiatives in Australasia. Academic plastic surgeon Michael Findlay has been appointed to direct the plastic surgery arm of this initiative—the Australasian clinical trials in plastic, reconstructive and aesthetic surgery (ACTPRAS) research group. While still growing, ACTPRAS has already facilitated two multicentre, international, collaborative studies—comparison of non-absorbable sutures versus absorbable sutures for skin surgery (CANVAS) and chlorhexidine versus iodine prep in hand surgery (CIPHUR)—where data on 3,494 and 2,454 patients, respectively, were observed at 92 centres. These large studies are powered to definitively answer unresolved clinical questions and thereby move practice into a more evidence-based sphere. Such large studies have additional benefits as they ameliorate many of the problems of smaller, single-centre studies such as confounder bias. Furthermore, these studies prime a network of teams and sites and produce evidence to apply for funded trials.

There is a common method to the studies run by ACTPRAS and similar collaborative groups which is best summed up by the democratisation of authorship, the appropriate use of technology and the large-scale recruitment of volunteer data collectors.

The increasing use of ‘group’ authorship on papers^8–10 has meant that scientific journals recognise valid, individual contributions. Hence, every collaborator in a large, multicentre study benefits from a publication that can be Medline listed and citable. The scale of collaborative studies can be global; the COVIDSurg observational study listed 15,025 collaborators who collected data on 128,013 patients in a record-breaking publication.^11,12 Most group author studies have fewer collaborators with Jamjoom and colleagues finding that the median number of collaborators on UK publications until 2015 was 207.¹³ The take-home message is that making studies democratic and rewarding, bypassing the traditional ‘first author’ positional hierarchy, can motivate contributions to large-scale, multicentre studies.

As collaboration has democratised the reward of authorship, technology has democratised the access to data and its sharing. Significantly, the robust research electronic data capture (REDCap) platform has proven itself as a data repository, wherever there is an internet connection. Video conferencing software has enabled virtual meetings and group ‘project pitching’ events, unaffected by geography or the COVID-19 pandemic. Social media and the ubiquity of email have opened access to surgical networks, through RACS and the Australasian Students’ Surgical Association, from which eager collaborators can be sought.

As a centralised computer network provides the infrastructure for collaborative studies, a distributed social network provides human collaborators. Volunteer data collectors can be recruited from the wider community of surgeons and allied health professionals. Because data collection skills can be taught to any grade of clinician, from student to retiree, the grade of the individual collecting information is less important than the number of collaborators. Each collaborator is prepared before collection, and the data they collect is validated at the study’s end, to ensure integrity. Often, the data collection task itself is simple and brief, making participation desirable because trainees can schedule it into a busy roster or it is conducted in an ‘in practice’ nature. The ancillary benefit of embracing trainee collaborators is that we nurture the next generation of academic clinicians to ensure the best and brightest grow through the ranks to fellowship.

In Australasia there are multiple plastic surgery research groups that, like ACTPRAS, all have a part to play in delivering high-quality evidence. The methods used by ACTPRAS are widely publicised to encourage collaboration. Thanks to a new generation of social media savvy trainees, who are both advocates for big data and public health, clinical research will develop on- and offline in an increasingly collaborative field. RACS has evolved the general surgical curriculum to reward participation in collaborative studies. As the plastic surgery community embraces novel changes to its training curriculum, it may be time to look to the future and ask if we want to keep up or lead?