Turning Practice into Research

Join Leah Hanson, PhD, HealthPartners Institute and Tullika Garg, MD, MPH, Penn State Health Milton S. Hershey Medical Center, as they discuss how clinical gaps play a role in practice and initiating research. They examine the different perspectives and roles of the patient, clinician, clinical staff and leadership in identifying those clinical gaps. They also consider barriers faced when trying to operationalize a research question. 

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Transcript

Leah Hanson, PhD: Hello. Welcome to the AGS AGING/ LEARNING Collaborative Multiple Chronic Conditions Research Podcast. My name is Leah Hanson. I'm a Senior Investigator at Health Partners Institute in Minnesota and Curriculum Co-Editor in Chief together with Dr. Heather Whitson at Duke University School of Medicine.

Today, we're talking about Integrating Research into a Learning Healthcare System, specifically turning Practice into Research. I'm pleased to welcome my guest today, Dr. Talika Garg. Dr. Garg is an Associate Professor and the Vice Chair of Research for the Department of Urology at the Penn State Health Milton S. Hershey Medical Center. She is a urologic oncologist and health services researcher focused on providing surgical care for medically complex older adults with bladder cancer. She was an NIA Butler Williams Scholar, an AGING Initiative MCC Scholar, and a GEMSSTAR awardee. Dr. Garg, thank you so much for [01:00] joining us today.

Tullika Garg, MD, MPH: Thanks so much for having me. 

Leah Hanson, PhD: So can you tell me about your clinical practice and how you first encountered multiple chronic conditions? 

Tullika Garg, MD, MPH: Yeah, absolutely. 

So I'm a urologic oncologist, and my practice mostly focuses on caring for people with bladder cancer. Bladder cancer actually has the highest median age at diagnosis of all cancer sites, it's 73 years. And our guidelines recommend really intensive treatment for this population both in early stage and in more advanced bladder cancers. And you know, I always It's been very evidence-based and guideline-based in my clinical management. 

But the patients that I was seeing in my practice were really medically complex and had a lot of questions about the benefits and the risks of treatment. And they had different goals than I realized a lot of other cancer patients may have, particularly [02:00] younger and less medically complex patients. So in trying to understand how to make these decisions, manage side effects from treatment, which may be worse in older adults with MCCs, I realized I was in a data free zone and I needed more evidence to help me to make these decisions.

Leah Hanson, PhD: So can you tell me about how recognizing that clinical gap sort of plays a role in your practice and initiating research? 

Tullika Garg, MD, MPH: I really, I think all of my research questions are driven by what my patients' stories are and their caregivers'. I feel like we're always, as clinicians, trying to do better by our patients, and there really are so many unanswered questions in medicine, particularly as we're thinking about people who are managing other chronic conditions in addition to their cancer. Identifying these clinical gaps really makes me a better clinician because I'm able to recognize that there are these questions where there's [03:00] uncertainty and that we need to try to find the answers. And I think it's also a really important part of being patient- and family- centered in our clinical care. 

Our patients also have a lot of questions and listening to them can help us to identify where we can improve our practice and tailor practice and really individualize our treatment to an individual's circumstances.

And, you know, I think as a clinician, we're really in a unique role because, we can be a bridge between full time clinicians and also full time scientists, and we can build that bridge between both clinical practice and scientific inquiry to help larger populations. 

Leah Hanson, PhD: Yeah, most definitely. And I really appreciate how you are looking at the different perspectives of the patient, the clinician.

And then, can you also talk about the perspective of, let's say, the clinic staff or the leadership in the clinic? [04:00] 

Tullika Garg, MD, MPH: Yeah, absolutely. I think a lot of clinical questions also come from, you know, our nursing staff who are on the front lines. They're seeing our patients, they're seeing the side effects, they're talking to them on the phone, and they're bringing those issues and concerns to us as physician clinicians. And I think that that can really impact, you know, identifying new clinical gaps. And you know, I think it's important to take into account all of those perspectives. 

And I think, you know, for hospital leaders, for department leaders, you know, payers, policymakers, understanding our older adults and our, medically complex patients and how we can improve care for them is, is really an important topic for a lot of those leaders as well. Providing them with that evidence and particularly evidence from the [05:00] perspective of the clinician or, you know, sharing the perspectives of our patients and caregivers to those leaders, I think, can really impact care on a broader scale. 

Leah Hanson, PhD: So now you've identified a gap, right, in the clinic and there's a lack of guidelines.

How, tell me, how do you turn that into a research question? 

Tullika Garg, MD, MPH: Yeah, I think it always starts with why. Why is something the way that it is? Why are we seeing this side effect in this particular population? Why are we seeing these outcomes are different in people with this condition versus another condition?

So, I think a lot of our questions initially start with why. 

Oftentimes what I start with is just going to the literature and looking to see if anything has been written on the topic, you know, is there anything available that can help me to answer my question? And, you know, I'll look not just in my specialty area of urology or urologic oncology, [06:00] but I'll look in other specialties or general surgery or colorectal surgeries and see what's been written. 

And you know, particularly for MCC's, you know, there often isn't a whole lot written. And so then I can take what's already in the literature, and then take what my patients, caregivers, and I myself am seeing and experiencing, and meld that together into the question. And, you know, for MCC's research, it can be really complex. And so, yeah, I have sought out a lot of guidance from existing research communities, like the AGING Initiative or the American Geriatrics Society to meet other like minded clinicians and researchers to help me to better define those questions after I've taken the initial pass on it. 

And then, you know, taking it one step further, I think there's a lot of great opportunities to think through study [07:00] designs. I personally have worked very closely with a statistician who has an interest in MCC's research and in complex retrospective data and helps to keep me honest in terms of my methodology to really think through how we can analyze the data to answer that question in the most scientifically sound way.

I would really recommend, you know, engaging a statistician or a methodologist early and often to help clarify your research question. Think about the data sources you could use and, you know, think about how to operationalize the study design. 

And then another big thing to consider is how MCCs will be defined in your research. And there are so many existing definitions of multiple chronic conditions. You know, are you going to think about two or more conditions? Are you going to think about three or [08:00] more? You know, are you going to use an existing index like Charlson Comorbidity Index? Or are you going to ask your patients and obtain your patient-reported You know, chronic conditions using a validated questionnaire?

So I think it's important to think through how you're going to define it and how you're going to collect the data. 

Leah Hanson, PhD: What are some of the barriers that you've faced and also facilitators as you've, you know, taken a research question and operationalized it? 

Tullika Garg, MD, MPH: I think for clinicians, oftentimes, the biggest barriers are time, feasibility, and resources.

You know, for me personally, I often have very big questions that are very macro. And I sometimes have to think through, well, is it really feasible with the time and resources that I have, to tackle the big question immediately? And I may not. 

[09:00] So then I think it's important to think about, is there a piece of the big question that you can break off and answer? And is that an incremental advancement in the bigger question that you may be asking? Is there something that you can generate some preliminary data on to move forward and perhaps get more time and resources to answer the next question, which may be a little bigger. And then it just kind of builds and grows from there. 

For a lot of particularly subspecialists, like myself doing this kind of research and you're really doing something new that hasn't necessarily been done in your field. And so just even doing these small early studies, and really start building a foundation within your specialty. 

You know, as far as facilitators, I mean, I think the number one biggest facilitator is [10:00] the MCC's research community. As a specialist, I've really found a lot of support in the research community, you know, through the [AGS] AGING [/LEARNING] Initiative and other excellent networks. You know, there's so many supportive colleagues. There's so many people who are generous with their time and knowledge in this area and willing to nerd out on on these questions. That's been incredibly valuable for me in my journey. 

You know, I think our patients are incredible facilitators as well. They are the ones who are coming to you with questions. They are helping you to rethink what you've always thought and believed. And they're really a wonderful gut check on whether you're asking the right questions.

You know, we've talked a little bit about hospital leadership as well. And, you know, I think hospital leadership has also been an incredible facilitator for me because, you know, they have a real interest in understanding [11:00] how to care for people with MCC's. And so, you know, I think it's important to remember that this work is really valuable to other stakeholders and you just never know where you're going to find that, that helping hand.

Leah Hanson, PhD: When you get results from your research, what are the different ways you communicate that back to, to your patients, and leaders, and clinic and the research community? 

Tullika Garg, MD, MPH: Yeah, I mean, I think there's multiple different levels at which the research can be shared. I mean, of course, you know, there's sort of the traditional venues, which are, you know, publications, presentations at academic meetings. You know, providing, you know, that kind of academic environment in which to share results. 

You know, I've shared results with you know, our bladder cancer support group, they've been, you know, really interested, they ask a lot of great [12:00] questions when you present to them. And it's a really neat way to, to get that additional gut check on your work, and a great way to get new ideas on what the next question may be. 

You know, I've also presented at, you know, we have a larger, a larger foundation that's focused on bladder cancer, the Bladder Cancer Advocacy Network. And I think some of these national foundations that are focused on your particular disease entity can be really valuable to disseminate results, getting it to the patients and the caregivers. And then also into nursing staff, advanced practice providers, etc. 

I think it's great to also get a couple minutes on an agenda for your faculty meeting to share with with your colleagues who may not be doing this kind of work so that they can understand a little bit more about their patient population and [13:00] and explain some of the things that they may be seeing clinically. I think it can be really very clinically relevant, even to people who may not necessarily be doing research per se, but are looking for ways to improve their clinical care. 

You know, of course, I think there are a lot of different venues. In hospitals and health systems to engage leadership, particularly if there are findings in your research that could lead to direct changes in clinical care or policy in the hospital.

Leah Hanson, PhD: It's really great to hear how you've incorporated, you know, taken your, your research and informed it from your practice and, and develop this health services 

research platform. 

Is there anything else you'd like to share with a clinician like yourself that might be considering entering into some MCC's research or any last minute pieces of advice?

Tullika Garg, MD, MPH: Yeah, I think this is a really [14:00] fascinating field. I think it's really fun and challenging to do this kind of work. You know, I think the biggest piece of advice I can give to clinicians who are thinking about this is listen to your patients, listen to your clinic staff, listen to your informal caregivers, and listen for those questions, and then find ways to try to answer them, and then engage the MCC's research community to help you answer those questions.

Leah Hanson, PhD: Well, thank you again, Dr. Garg, for joining us today. And thank you everyone for listening.